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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrflFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. mss:/S'oZf <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z1_2a-,7C- <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 wade 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 J21 -7 5 . S I' N CENSUS TRACT <br /> Owner's Name Phone d 9 <br /> Address City <br /> Contractor's Name Tjt7. Su TTaN 4 Sra �y License Phone 07 <br /> s <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN /? RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT 1 f <br /> Other L 7 <br /> h <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT_PRIVY__ <br /> "SEWAGEDI <br /> - SPOSAL FIELD -'' �- CESSPOOL/SEEPAGE PIT OTHER <br /> ' -•PROPERTY- LINE - PRIVATE DOMESTIC WELL PUBLIC bOMESTIC WELL 1 <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .v. <br /> Industrial 4 ` . Cable Tool Dia. of Well Excavation <br /> r Domestic � "Drilled Dia. of Well Casing " <br /> /private <br /> Domestic/public , Driven Gauge of Casing _ <br /> Irrigation Gravel Pacts Depth of Grout Seal - <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal . Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: J/ State Work Done <br /> ,. <br /> ~PUMP'TREPAIR:"'`"""`°�`� f'°'State Work Done P - <br /> .. . <br /> ES-TRUCTION 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 construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well,_ I.will .furnish the-San., Joaquin .Local.Realth .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 ,4 FINAL INSPECTION. <br /> SIGNED -7TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> .- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE �� <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />` � E H 1426 Rev. 1-74 1_74 9M <br />