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►i` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-.�,7 <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 /> JOB ADDRESS/LOCATION /9 ' Aj CENSUS TRACT <br /> Owner's Name 63 J1h0 Phone e3,38 26a7 <br /> Address ��? O�! City Z s c"/9,4 O'`-J <br /> Contractor's Name License # ),q)) JPhone M-,.)2 <br /> TYPE OF WORK (Check) : ' NEW WELL / / DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / FUMP REPAIR/ / PUMP REPLACEMENT /N <br /> Other'-.L_/ -- — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 4 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> IrrigatYgn Gravel Pack 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.P. <br /> PUMP REPLACEMENT: State Work Done d6 <br /> ,001 <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 '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 GROUTING AED A FINAL INSPECTION. <br /> SIGNED ,� TITLE <br /> r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Q T SPECTION PHASE II/F AL XNSPECTIOV, <br /> INSPECTION BY 15ATE INSPECTION BY <br /> ,.4DATE <br /> c - <br /> E H 1426 Rev. 1-74 1177 - 2M <br />