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SAN JOAQUIN .LOCAL HEALTH DISTRICT CU <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is l�ieretr made t� the San Joaquin Local Health Di4trict 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 _�� � g V�� /�� - CENSUS TRACT <br /> Owner's Name - Li4L4Z4 TT Phone �. 1z d< <br /> Address / �i - evert' /Ce�- City <br /> Contractor's Name License #, ��/Iy Phone - J <br />, TYPE OF WORK (Check) : NEWWE L /�/ DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / '/ PUMP REPAIR / / PUMP REPLACEMENT <br /> IE <br /> Other ,/ <br />'t DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES ---SIT PRIVY <br /> F SEWAGE i • <br /> DISPOS HELD CESSPOOL/SEEPAGE PIT OTHER ---� <br /> PROPERTY LINE PRIVATE DOMESTIC WELL --=--PUBLIC DOMESTIC WELL <br /> INTENDED USE x „TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 'w 1 1/ Cable Tool Dia, of Well Excavation <br /> Domestic/priva.te P Drilled Dia, of Well Casing <br /> Domestic/public', Driven Gauge of Casing Lra <br /> Irrigation Gravel Pack Depth of- Grout Seal t <br /> " Cathodic Pro tectiori_r _ <br /> Rotary, _._ ""_,Type of,. GroIC <br /> Disposal Other Other .'Information <br />' Geophysical" +.*��• 4 Surf ace Seal Installed By: <br /> PUMP-INSTALLATION: Contractor J "a Xto <br /> Type of Pump H.P. s <br /> PUMP REPLACEMENT: / / State'Work Done <br /> PUMP REPAIR: State Work DoneT . <br />�DES•TRUCTION OF. WELL: Well Diameter 'r Approximate Depth ' <br /> Describe Material and Procedure r. <br /> II 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 newowell,, ill furnish the San Joaquin Local Health District a <br />! WELL DRILLERS REPORT of the wan em before pitting the -well in.-use. The above <br /> , informati true the be tF ofe and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR GR /A FINA INS CSIGNED i TITLE i <br /> (D W.PLOT PLAN ON REVERSE SIDE) <br /> !` TM FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> . APPLICATION ACCEPTED BY o, DATE d <br /> ADDITIONAL COMMENTS: , -- <br /> "PHASE'"II'GROUT"INSPECTION �INSPECTI N <br /> INSPECTION BY .___. .. DATE LZ <br /> _INSPECT.I"ON�BY �. DATE_ , <br /> E H 1426 Rev. 1-74 <br /> ; 117:7 2M <br />