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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICEjUSE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI Permit No. 7:Z-33 k/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued1 <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District foi a permit to construct- <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regula ons of the San Juin Local Health District. <br /> JOB ADDRESS/LOCATION G� a hf 1 CENSUS TRACT <br /> Owner's Name ? S. ~ �l Phone � �� <br /> Address L }�It^GY�/' 1��� f� city <br /> Contractor's Namerte'f 1)tLn C6 - _Tiv License i�f0$I3 Phone5- 0� � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK MILC SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER Y�{j7L� <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 V# cu. T-- <br /> _ Irrigation �_ Gravel Pack Depth of Grout Seal mane G, <br /> Cathodic Protection )< Rotary Type of Grout Nene- T <br /> Disposal Other Other Informationl� <br /> Geophysical Surface Seal Installed By.: not D <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �L <br /> PUMP �.REPAIR: / / 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 Healthistric <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1QS /1j-nr4o _:rn{,. hU TITLE <br /> (DRAW PLOT PLAN ON MERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C �,1 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR T INSPECTION PHASE UI41FIN4 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATESQ2-1— /7. <br /> E H 1426 Rev. 1-74 <br /> 117.7 ., 7M <br />