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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE 2FFICE'USE:. 1 4:�11601 E. Hazelton Ave. , Stockton, Calif. <br /> / Telephone: {209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 _/pa <br /> THIS PERMIT EXPIRES 1 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> A <br /> JOB ADDRESS/LOCATION 4 jaw,6 CENSUS TRACT - <br /> Owner's Name 2 Vf <br /> 1- Phone <br /> f � ' <br /> 9 <br /> Address 449 e-6 , City \10,110 k6 � <br /> iContractor's Name License # -7 Phone 44CX, -7474 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION/_7 <br /> PUMP INSTALLATION Z/ -"PUMP REPAIR / J PUMP REPLACEMENT T7 <br /> Otherl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ .,. <br /> SEWAGEaDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIME - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF ,WELL CONSTRUCTION SPECIFICATIONS : <br /> Industrial ! Cable Tool Dia. of Well Excavation <br /> x Domestic/private i Drilled Dia. of Well Casing v <br /> Domestic/public ! Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of'Grout <br /> Disposal j Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION4 Contractor ` PJ s'� . <br /> Type pf Pump .S' H.P. / <br /> PUMP `REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 'State Work Done <br /> f <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'constructi.on. 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-Vest of my- knowledge and belief. A WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI . <br /> SIGNED E <br /> �- (D!A= T PLAN 'ON REVE E SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /4- <br /> ADDITIONAL COMMENTS: - <br /> PHASE II G INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY V DATE INSPECTION BY DATE _ <br /> �_. 3/76 <br /> E H 1426 Rev. 1-74 <br />