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t <br /> /a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s FOE;OFFICE USE: 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 ]. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Aprilication is hereby mads to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This app3ication 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 /> Jos ADDRESS/LOCATION "~ `tort, CENSUS TRACT 0 t -Z-&o-.al <br /> 5.� l <br /> Owner's Name Phone ' <br /> !� . <br /> Address _ . ,,. Ifs A-' 6 LI2 e -- City S��. <br /> Contractor's Name �iye? c .-� License ' Phone 7 ••7j. <br /> TYPE OF WORK (Check) : NEW WELL.'/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/; PUMP REPLACEMENT / 7 <br /> Otherl/% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELT.' PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial € Cable Tool Dia.. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> yC 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 /> i <br /> PUMP INSTALLATION: Contractor „ <br /> Type of Pump ✓ H'.P, p <br /> PUMP REPLACEMENT: . / / State Work Done Y _ <br /> PUMP '.REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL: - Well Diameter Approximate--,_.... PP Depth <br /> Describe Material and Procedure <br /> j <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 oh 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-be'at <br /> of my_ owledge and belief. I WILL CALL FOR-A ,GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALIINSPECTION. <br /> SIGNED �/ aK W." TLE <br /> 1 DRAW PLOT P ON REV RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRA S INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r' s./tee aiu <br />