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-SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1---1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> L� tfD THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> U (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 �t�/he Rules 6an�d R/e_gtulat'io�nsf the San Joaquin Local Health d District. <br /> JOB ADDRESS/LOCATION /"' Gov N v�'9�r��"'•A ' ��}& el�►r1�T Com, <br /> //t- �iSUS TRACT <br /> Owner's Name (',.:._1•e Phone IS, Z 3 <br /> J <br /> Address 1 -It g ►=� 'r n�,r I.J City <br /> Contractor's Name A)*$ %1�0.�c /'�n��;c!jr-* 01 License #9q(, (-L- Phone <br /> S5`I-3gS6 <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION &W PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <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 /> _q 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 Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ,.t-S <br /> Type of Pump H.P. ) <br /> PUMP REPLACEMENT: / State Work Done <br /> PUNP :REPAIR: /7 State Work Done <br /> ZES-TRUCTION 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 thewell 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED [, ,_ k TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , l DATE ° <br /> ADDITIONAL COMMENTS: <br /> PHASE XX GROUT INSPECTION PHASEAdII/FINAVINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .• ' <br /> E H 1426 Rev. 1-74 1-74 2M <br />