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SAN JOA UIN LOCAL OCAL HEALTH DISTRICT <br /> F0_R,OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif: <br /> Telephone: (209) 466-6781 ,. <br /> APPLICATION FOR"WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,0 _,qo p <br /> THIS PERMIT EXPIRES 1 YEAR 'FROM DATE ISSUED Date Issued I <br /> (Complete In, Triplicate) I�. <br /> Application is hereby mode to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is madilin compliance with San Joaquin <br /> County Ordinance� No. 1862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESSILOCATION 2 Q S' 3' CENSUS TRACT <br /> Owner's' Name Sj2 MIL <br /> ' % Phone <br /> Address .4 . City 4L9641.6 1.) <br /> Contractor's Name S� • License #62-am(nd !hone 'gwae _2v <br /> TYPE OF WORK (Check): NEWWELL/� ,•DEEPEN L/7 RECONDITION [7 DESTRUCTION /7 <br /> PUMP INSTALLATION "°;J -/ 7-PUMP, REPAIR - <br /> . 1.2 PUMP- REPLACEMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEIPIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDEDiUSE 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 Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ' <br /> _ y Type of Grout : . <br /> h <br /> Disposal O 3 .. <br /> P ter Other <br /> Tnforinatioa <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Ty i of Pump <br /> H.P. <br /> PUMP REPLACEMENT: 1 -.I• .. � <br /> / / State Work Done } A <br /> PUMP �REPAIR: Jif State Work Done i <br /> DESTRUCTION OF WELL: :Wel:l,--Diametez ,, -Approximate Depth. <br /> Describe Material-,.-and• Procedure <br /> , , . <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 TING AND AL INSPECTION. <br /> SIGNED TITLE` <br /> DRAW PLOT PLAN ON REVERSE SIDE ; <br /> ME APARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTS DAT ` 7 <br /> ADDITIONAL COMMENTS: 1Y,,94JA10TVI�. � <br /> PHASE II GROUT INSPECTION PHAS F INSPECTTO <br /> INSPECTION BY DATE INSPECTION <br /> BY TE <br /> E H 1426 Rpt_ 7..74.' r^ t.h7e nu <br />