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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./72 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In -Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install 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 , r0 Z 2 CENSUS TRACT <br /> Owner's Name Phone <br /> Address City nC2141a _ <br /> Contractor's Name License # <br /> av-9&Z-4hone Q� <br /> TYPE OF WORK (Check) : NEW WELL / /'`�DEEPE'N /_/ RECONDITION /_/ DESTRUCTION /7 <br /> k PUMP INSTALLATION'/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other',./r./ �' • f <br /> DISTANCE TO NEAREST:--S <br /> `EP­T_IC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -- PRIVATE DOMESTIC WELL PZIBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable ToolDia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �► <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1 Other ._ `, Other Information <br /> Geophysical �. <br /> s^Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ` F'r <br /> Type of Pump H.F. ' <br /> f <br /> PUMP REPLACEMENT: State Work Done <br /> � <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ## <br /> Describe Material and Procedure 1 <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local ,Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. , 'The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A FINAL NSPECT N. <br /> SIGNED TITLE <br /> (DRAW PWT PLAN ON REVERSE SIDE) , <br /> PHASE I <br /> DEPARTMENT USE ONLY OA <br /> APPLICATION ACCEPTED BY �l/�✓ DATE <br /> ADDITIONAL COMMENTS: j <br /> PHASE II OU N C 0 P S 12 /FINA I SPECTIO <br /> INSPECTION BY TE INSPECTION BY N AT 7 <br /> E H 1426 RPv_ . 1-74 �• 6177 PM <br />