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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ ;?OpO <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 /> JOB ADDRESS/LOCATION p�/ CENSUS TRACT <br /> Owner's Name j PhoneM-- 7?Z <br /> Addresscit <br /> a r <br /> � . y �.����' <br /> to,.- F. <br /> Contractor's Name , ,� � ��- - License faa��7 Phone � d� <br /> 3 <br /> TYPE OF WORK (CtieCk) : _PEW WELL';/ / DEEPEN / / RECONDITIQN / /- DESTRi7C3ION <br /> UMP INSTALLATIONS PUMP REPAIR:/ / PUMP ,REPLACEMENT /� <br /> Other LZ L, . +t7i' --S° !?''� �s.�1 '[c <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- ,-- V\ OTHER,'-A <br /> PROPERTY LINE - PRIVATE DOMESTIC 'WELL`` - ''_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> . Cable Tool "j Dia. of Well Excavation', <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven r1 Gauge of Casing <br /> Irrigation Gravel Pack jDepth of Grout Seal <br /> Cathodic -Protection Rotary /.Type of Grout <br /> Disposal Other /"Other Information <br /> Geophysical Surface Seal Installed By: „__....._.-._ <br /> PVRP INSTALLATION: Contractor 2, JR 722 <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: / / State Work Done i <br /> �.*Cry <br /> =PUMPS 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 i <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 GROUTINGD A FIN N5PECTION. i <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FO EPARTMENT USE ONLY y <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I ` ROUT INSPECTIONPHA III/ IN INSPECTI N ' <br /> INSPECTION BY DATE INSPECTION BY ;� DATE <br /> !. . 117.7 <br /> 2M <br /> E H 1426 Rev. 1-74 , <br />