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A,, SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR.'MPIM SE: t� 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 <br /> (Complete In Triplicate) <br /> Lpplitation is Aereby made to the San Joaquin Local Health District for permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquin <br />;ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> t � <br /> TOB ADDRESS/LOCATION h� z if -�I�l� W, Ooa l�'t'JlrC.I, PL( sF `�iGI CENSUS TRACT <br /> haner's Name1l�„!1�„ ), i"t - Phone <br /> Address 1.9,-j J irft r ��1.'(�� City <br /> T t License # Phone <br />..ontractor s NameX11'1►Rrcb. �r I I Y f rY_� <br /> i <br /> TYPE OF WORK (Chock): NEW WELL /7 DEEPEN/_- RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / /PUMP REPLACEMENT <br /> Other f� , <br /> DISTANCE TQ NEAREST: SEPTIC TANK SEWER LINES -- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 2V PUBLIC DOMESTIG WahINTENDED USE TYPE OF WETL' 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 /> Disposal Other Other Information --- � 4 <br /> Geophysical, Surface Seal Installed By --- <br /> RUMP INSTALLATION: Contractor .ig eS R <br /> Type of Pump /T,,.: � ,�r H.P. ,,,�._` <br /> PUiT' REPLACEMENT: / / State Work Done <br /> r T <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 Health btitrict <br /> and .the State of California pertaining to or 'regulating well"construction. Within FIFTEEN PAYS <br /> aftor completion of my work on a new well, I will furnish the San Joaquin Local Health Distrtet 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 GRQUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT'PLAN ON REVERSE' SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DACE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROfJT INSPECTION PHASE II FIN NSPECT <br /> INSPECTION BY DATE INSPECTION BY DTE <br /> : 1/.77 ' � <br /> E H 1426 Rev. 1-74 <br />