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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _70K-.'OFFICE USE: 1601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T 9 <br /> 7d-96�}o.4'91S PE PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> . (Complete In Triplicate) <br /> Application is hereby made to the Sdn 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 <br /> I <br /> - - •,,,.. '����.- .....� CENSUS TRACT <br /> Owner's Name <br /> Phoned- / . f" <br /> Address 4ZIL City . . .. <br /> rt <br /> 'CfP <br /> Contractor's Name _ , 4 <br /> License Phone f'f,.�'- S' �1 <br /> TYPE OF WORK (Check): NEW WELL '/77'DEEPEN -/-7 RECONDITION /_f• DESTRUCTION /7 <br /> PUMP INSTALLATION /v_�PUMP REPAIR'/_7 PUMP REPLACEMENT / <br /> Other <br /> DI-STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT�- t OTHER 3 <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 />=omestic/private Dri11d Dia. of.Well Casing <br /> Domestic/public, Drivven ... Ga o€ Casing A2 <br /> Irrigation Gravel Pack Depth of Grout Seal ..— �j <br /> Cathodic Protection RotaryType of Grout <br /> Disposal Other Other Information ' ' <br /> Geophysical Surface Seal Installed l . <br /> PUMP INSTALLATION: Contractor <br /> Type of-• Pump H.P. <br /> PUMP REPLACEMENT-. . / / State kork Done <br /> PUMP :REPAIR: wState Work Done <br /> DESTRUCTION OF WELL: Well D terms Approximate Depth <br /> Describe- Material and Procedure <br /> I hereby agree to comply urith all—laws--and--regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "const,ruction. 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.Mthe-well and-notify" them before-putting-th0a well]"-ifi iu :-".'The a ei <br /> information is true to the-best-of- my..knowledge and belief:"i ,I WILL-CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AN <br /> D_A FINAL INSPE ION.. �- <br /> SIGNED '� F @- � �.� TITLES Y <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �2 <br /> kDDITIONAL COMMENTS: <br /> - PHA T INSPECTION' PHW =4MMAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 77. <br /> E H 1426 ev. 74 .��„[�� tl"7' -'� <br />