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- �1 V SAN JOAQUIN LOCAL '.HEALTH DISTRICT <br /> FO$rOFFICE USE: 1601 E. Hazelton'Ave. , Stockton, Calif. <br /> Telephone: --(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7-17--Z96 )0 <br /> THIS PERMIT EXPIRES 1 .YEAR=FROM-DATE ISSUED Date Issued ;�l - -2 7 <br /> t (Complete In.Trip.11cate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <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 f 5-6- �'• W�ic� rA001, CENSUS TRACT <br /> Owner's Name r.{ t Ljc)0CjS - Phone <br /> Address 5 r:. r 1 �. City � j20 s1 <br /> Contractor's Name /)14�; leo inz, 1q <f- �i'. License # Phone <br /> TYPE OF WORK (Check): NEW WELL -/ 7 DEEPEN -/-7. RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR 1_7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP00L/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 Casing <br /> Domestic/public Driven Gauge of Casing <br /> Y 'Irrigation- - T �.--Grave r 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 kd S 'i-o WI!L , �a (fin <br /> Type of Pump H P"..,_. ; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: L7 State Work Done <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 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 AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE - <br /> - FOR DEPARTMENT USE ONLY ---- <br /> PHASE I <br /> APPLICATION ACCEPTEb BY ' .- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT:INSPECTION PIII NAL TNSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE <br /> :E H 1426 Rev. 1-74 1_7A W <br />