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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR30FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR..PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .3- 2ji_7( <br /> ' (Complete In Triplicate) <br /> Application is hereby made to the San' Joaquin Local Health District for a permit to construct <br /> and/oijnitall the,work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . 9-VAI <br /> . N. CENSUS TRACT <br /> .i <br /> Owner's Name ' PhoneR,392 /7 <br /> Address' '=' a C, . City L5C A0j <br /> Contractor's rNarrie ' ,v ;,� , . "D w License #07 0 Phone 0'7 <br /> f TYPE OF WORK (Check): NEW WELL/? DEEPEN -/_7 RECONDITION J� DESTRUCTION /-7 <br /> PUMP INSTALLATION f_1 PUMP REPAIR X PUMP REPLACEMENT % 7 <br /> - Other L 7 d <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> �. <br /> SEWAGE DISPOSAL FIELD r .ZESSPOOL/SEEPAGE PIT OTHER <br /> ,• � PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toci,;;� Dia of 'Well Excavation <br /> Domestic/private Drilled Da�of Well Casing <br /> Domeetic/public Driven' <br /> ,, Gauge _of casing - <br /> Irrigation ' Gravel~ Pack"'� I)epth of Grout Seal <br /> Cathodic Protection Rotary -- Type of .Grout <br /> Disposal ; Other Other Information <br /> Geophysical _ 4 f.} ' ^ ' Surface"Seal Installed BY: <br /> - a <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUNT .REPAIR: 7 State Work-D e <br /> + 1�E,pL0jc r„p <br /> ES.-TRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> I hereby agree to comply with all laws-.and regulations of the San Joaquin Local Health District <br /> and the State,'of California perialAng=ro or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local H.ealth .District a <br /> WELL bRiLLERS REPORT of the well and notify them before putting..the. well in use.. The above <br /> i ' information is true to the-bestof- my knowledge and belief.- I WILL CALL F(} 'A GROUT INSPECTION <br /> PRIOR TO ,jKUT NG ANDA FINAL INSPECTION. <br /> SIGNET}') TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) - . <br /> t ' <br /> PHASE I b �. <br /> FOR DEPARTMENT USE ONLY <br /> ` � <br /> APPLICATION ACCEPTED BY `` DATEa � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE k INSPECTION- BY DATE �27767, 76 <br /> 1 E H 1426 Rev. 1-74 I 1-7442M _ <br />