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1 ZY/6 <br /> SAN JQAQUTN .LOCAL. HEALH DISTRICT <br /> EOVOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �T <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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. 186,2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION B�-� CENSUS TRACT <br /> Owner's Name Phone g,-z2E- <br /> Address City �S ��-��✓ <br /> Contractor's Name License #C7z_j­7 Phone <br />'�-�4TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / 'DESTRUCTION /_ <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/a&,, S EW <br /> _ER; LINES�� PIT PRIVY* <br /> SEWAGE- OSAL IELD _ CESSPOOL/SEEL'AGE Pik OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL .-Z a ..` <br /> INTENDED USE TYPE OF WELL lQ +. CONSTRUCTION, SPECIFICATIONS �. <br /> Industrial J� Cable;Tool f Dia.kof Well Excavation ti <br /> Domestic/private t;�- �' Drilled _._..Dia: of Well`Casing—s_. - :S' <br /> Domestic/public---' " ` Driven Gauge of Casing N , 1. / <br /> Irrigation Gravel Pack 16epth of Grout Seal <br /> Cathodic Protection' Rotary Type_of,-Grout...- <br /> Disposal Other Other Information 7111-) <br /> Geophysical Geo h <br /> p y _ .�`f'` Surface Seal Installed By: QW-v`e-t- , <br /> PUMP INSTALLATION:, Contractor __j';� --'�/L�?- '��7 f r <br /> Type of Pump' <br /> r PUMP REPLACEMENT: / / State Work Donee •/ <br /> 'UMP L/ _State Work D6ne <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 -c'onstruction.m Within FIFTEEN DAIS <br /> after completion of my work onNa 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. IThe 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:1 SPECTION. <br /> G SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> mak. FOR EPARTMENT USE ONLY <br /> } . <br /> PHASE I <br /> APPLICATION ACCEPTED BY;, - DATE ela 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE A7 INSPECTION B DATE•�Z—ZZ-7� <br /> 1, 77 . 2M <br /> E H 1426 Rev. 1-74 <br />