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SAN JOAQUIN LOCAL 'HEALTH DISTRICT'' _ <br /> FORrOFFTCE USE: 1601 E. Hazelton Ave. , Stockton; Calif':',' <br /> i Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZL-0 O 6 <br /> THIS PERMIT EXPIRES 1 YEAR=FROM DATE-.' 9U Date Issued <br /> I (Complete In Triplicate) ' <br /> Application is hereby rade to the San Joaquin Local Health Di�stt ct Tor' e permit to construct <br /> and/or install the .work herein described. This application-is taAde in compliance with.San Joaquin <br /> County Ordinanc No. 1862 and the Rules and Regulations of, the 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, ' - <br /> S CENSUS TRACT _.:0 g-fro pl <br /> °s Name ,� " <br /> Owner ; <br /> Phone <br /> AddressS S =..� <br /> City ' <br /> Contractor's # l/„ 3 <br /> actor s Name �_-•_ �� ' � - - ..,,., '' . ,.. License .het Phone l <br /> :TYPE OF WORK (Check): NEW WELL '/? DEEPEN /7 RECONDITION /_ DESTRUCTION /7 <br /> PUMP INSTALLATION ZF PUMP REPAIR /_7pUNP REPLACEMENT <br /> Otherp/ <br /> / <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER`LINES PIT PRIVY V <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 r Dia. of Well, Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> --!Cathodic Protection ` 1 Rotary Type of Grout' <br /> Disposal Other- Other Information <br /> Geophysical --- °Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 7S <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPtREPAIR: /_7 State Work Done r <br /> � r <br /> E&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.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 TITLE <br /> f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT U NLY <br /> APPLICATION ACCEPTED BYEzz"! <br /> ADDITIONAL COMMENTS: DATE, Sr7G <br /> PHASE II GROUT INSPECTION PHASE IIIaINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .� DATE <br /> E H 1426 Rev. 1-74 i_7c. <br />