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SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> F0ArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,��S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -Date Issued S 7=T--s— <br /> (Complete In Triplicate) <br /> Application is hereby made to the San: Joaquin Local Health District for­a permit to construct <br /> and/or install the work herein described. This application is made it 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 ""`Yo� y""' (�.f��o:�-s�+ '� -CENSUSTRACT <br /> Owner's Name JZayA1 Aell e e!v Phone <br /> Address �'� 7—E6 fc-.4 4, L_B /v A city , <br /> Contractor t s Name �� r/ /�,p � `�' License # Phoneme` <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /7 RECONDITIONDESTRUCTION _(7 • <br /> ALd <br /> PUMP INSTALLATION /-7 PUMP REPAIR 'UMP REPLACEMENT f7 <br /> Other /J ! <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 <br /> Domestic/private Drilled Dia. of Well Casinig - <br /> Domestic/public Driven Gauge of Casing <br /> 7--I-rrigation 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 R lit- H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP :REPAIR: - - / State Work Done ,��� ,�.�. 1 ,-�• °c <br /> ,pES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <br /> I hereby agree to comply with all.�Adws 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 <br /> WELL DRILLERS. REPORT of the well and notify them before putting the-well in use.. The above <br /> izzformation is true to td—best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AN FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY f DATE- j <br /> ADDITIONAL COMMENTS: <br /> F PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />, I E H 1426 Rev. 1-74 1-74 2M <br />