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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE_ f'ifFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -s Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p1� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3� <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 /> C/d t Ro b ert"r-p Ca o a 7— 6 2 <br /> JOB ADDRESS/LOCATION Cc 13 pj�, <br /> .6 c -c CENSUS TRACT <br /> Owner's Name /l Phone qS Z <br /> Address 3 j CityL,-Oe.�`"at-1 . <br /> Contractor's Name License #� .,� Phone <br /> -, <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /2;L PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> ,.Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ! _ SEWER LINES S , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' U' CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE/ PRIVATE DO STZC ELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled {� / Dia. of Well Casing <br /> Domestic/public Driven" v Gauge of Casing <br /> Irrigation Grave �a k Depth of Grout Seal <br /> Cathodic Protection t Type of Grout <br /> Disposal a Other Information, <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contrac or4/V1 !/'( UN t� 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 'con"struction. 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 IN PECTION. <br /> SIGNED TITLE <br /> ,,44. <br /> W..PI�, T PLAN ON RE ERSE SI <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYc. <br /> 141am� DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />