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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z f O C 6J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �o ­43-7(f <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 ��j S' , Ai- R CENSUS TRACT <br /> Owner's Name 1 A 13ZZ Phone .�i f ' lam. <br /> Address Cit <br /> Contractor's Name + � License Phonej. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION AL / /_7_/ DESTRUCTION / _ <br /> PUMP INSTALLATION R, REPAIR / V/ PUMP REPLACEMENT <br /> Other <br /> cr <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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor T �� 7 L,��,1 tl��� 4-,/ <br /> Type of Pump j s is Ad Z H.P. As <br /> PUMP REPLACEMENT: / / State Work Done <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 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 FORfA GROUT INSPECTION <br /> PRIOR TO GRO NG AND INA INSPECTION. /Z I __1 <br /> SIGNED , TITLE_-�r -c <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FIN4 INSPECTION <br /> INSPECTION BY DATE // _ INSPECTION BY DATE 7 B <br /> 0/77 2M <br /> E H 1426 Rev. . 1-74 <br />