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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_R_75FFICE USE: 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ate_ 6 8Eg ,�, <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-3o-7G <br /> i` (Complete In-Triplicate) <br /> Application is "hereby made tb the Sass Joaquin Local Health District for a permit to construct <br /> rind/or install the work herein described. This application is made in compliance with San Joaquin <br /> i Coenty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1, JOB'ADDR9SS/LOCATION Cw .1 !.r✓AW, CENSUS TRACT <br /> Owner's Nsme. Phone ' -S550 <br /> Address = } <br /> � s City . <br /> Contractor's Name License #�. 7 Phone Z <br /> mm <br /> TYPE <br /> f. .-. .J0...._._y., -�:�L 4-� S.-a�• -?- + - <br /> „T' .- �.s n_�,... �..�.,.. .ter--;-.,.'�__-"-_ •-�-_ _ „_..-.-__,�.-_ ��_.�-__y <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /-7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION 1_7PUMP REPAIR PUMP REPLACEMENT / f <br /> Other/ / . <br /> .DISTANCE TO NEAREST-: SEPTIC TANK SEWER LINES ' - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> `PROPERTY LINE -- PRIVATE •DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool ~ Dia. 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 /> I� Disposal Other Other Information <br /> Geophysical ..,��e... ....x <br /> -Su�face"'Sea]."`Insta]:led'By i <br /> rA <br /> PUMP INSTALLATION: Contractor ^ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT . tate ork Do% S n <br /> / e <br /> : M <br /> PiII _1REPAI�t;�y J State Work Done <br />! DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <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 af-'my.:knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUT G ' <br /> D A IN INSPECTION. <br /> SIGNED TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE 0 <br /> R. L FOR DEPARTMENT USE ONLY <br /> PHASEtiI: <br /> I APPLICATION.'ACCEPTED-:-BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE► I INAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION B ° DATE Q : <br /> E H 1426 Rev.. 1-7G e owr <br />