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�8f SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOF ;OFFICE USE: j 1601 E: Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ec� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued?_f-l� 7:(,. <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 "/,g S <br /> 7O 1*6 CENSUS TRACT ' <br /> Owner's Name kePhone <br /> Address <br /> /2 <br /> City. wlc 2`01? <br /> Contractor's Name <br /> o S 1. LG License #A," Phone 3 g ys <br /> TYPE OF WORK (Check): NEWWELL / DEEPEN. /? RECONDITION /? DESTRUCTION /_7 <br /> Other SPALLATION / / PUMP REPAIR :/ ] PUMP REPLACEMENT <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK 13-a— SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL--FIELD­ CESSP00L/SEEPAGE'PTT oHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL-. _._-P-UBLIC' DOMESTIC�WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable .Tool = Dia. of,Well Excavation <br /> Domestic/private DrilledDia. -of_Well. Casing ip <br /> Domestic/public Driven r ... Gauge of Casing /D <br /> Irrigation Gravel Pack -- Depth.'of Grout Seal . t ,. IN <br /> Cathodic Pr_otec__tion .. 'Rotary - Type 'of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATIONS Contractor <br /> Type .of Pump H.P. Ze <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP '.REPAIR: <br /> /F :State Work Done <br />)E3_TRUCTION_OF.WELL: Well:-Diameter -- <br /> A-pprox <br /> Describe Material and Procedure # <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District t <br /> Ind the State of California pertaining to or regulating well ''eonstruction. Within FIFTEEN DAYS <br /> 3fter ,completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting..the..well. in.use.. . .The 'above <br /> Lnformation is true to-the,best.o£ my. knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br />'RIOR TO GROUTING ,AND A FINAL INSPECTION. <br /> UGNED c <br /> TITLE y <br /> D PL ON REVERSE SID <br />'RASE I <br /> FOR DEPARTMENT USE ONLY , <br /> - <br /> LPPLICATION- ACCEPTED BY <br /> ._. DATE <br />►DDITIONAL C :7 <br /> OMMENTS: -� kk <br /> ALI <br /> PHASE II GROUT INSPECTION HAS IIF INSPECTION I <br /> INSPECTION BY DATE , YNSPECTION ATE <br /> E H 1426 Rev. 1-74 <br />