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SAN JOAQUIN LOCAL HEALTH DISTRICT SIC <br /> E FOR.OFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued c2 IK_7fl <br /> s j (Complete In Triplicate) <br /> Application is hereby made t9 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 /> s County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONy 61 � �'O IQ�..�1& y4 CENSUS TRACT <br /> p <br /> E Owner's Name <br /> i ! tesGn Phone 3 <br /> Address - �� u �'D P L Cit <br /> E Y v .� p <br /> Contractor's Name GV Q. e �' License # � phone .� -7cl <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 "l4 <br /> Other I/ / <br /> �+r. <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .13 'f CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br />: _J� Domestic/private Drilled r Dia. of Well Casing �� �- <br /> Domestic/public g Driven Gauge bf, Casing <br /> Irrigation k Gravel Pack Z• <br /> i Depth of Grout Seal / <br /> Cathodic Protection — Rotary Type of Grout <br /> Disposal <br /> Geophysical <br /> Other Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: "/ / State Work Done <br /> PUMP 'REPAIR: ' a <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r <br /> 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 'construction. Within FIFTEEN DAS <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 GR ING AND A FINAL INSPECTION. <br /> SIGNED TITLE ` ■ <br /> 17 (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> a <br /> PHASE- II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> J _ DATE - ' 7 a' <br /> EH 1426 <br /> R v. 1-74 i /77 IOU <br />