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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F016i0F ICE USE. " i f//"1601 E. Hazelton Ave. , Stockton, Calif. <br /> � k Telephone: (209) 466-6781 <br /> APPLICATION FOR 'JELL CONSTRUCTION OR PUMP PERMIT Permit No. I}�P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedW_ <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION a.o P. A/ Dm t)ritnP rQW 0�®Ka' CENSUS TRACT_ <br /> Owner°s Name !o-yu. Phone <br /> ' Address D 6 ®X, /fid' City Vo ocw ry�� <br /> Contractor's Name License # egs'h�Phone y- d L <br /> ' TYPE OF WORK (Check)- NEW WELL /7 DEEPEN/7 RECONDITION /7 DESTRUCTION FT <br /> PUMP INSTALLATION [7 PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other / <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 Casing = <br /> Domestic/public Driven Gauge of Casing J <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> ' PUMP INSTALLATION% Contractors ¢GG� u,.-� <br /> Type of Pump 6 Zr- H.P. k <br /> C <br /> ' PUMP REPLACEMENT. � State Work Dona <br /> UMP".REPAIRiState-Work..Done - <br /> RwiRUCTION OF WELLS Well Diameter 1. 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 puttingthewell 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 INSPECTIO <br /> SIGNED s. ITLE <br /> ' T PLAN ON REV RSE SIDE <br /> ZOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11N4PECTrON PHASE III FINAL INSPECTION <br /> ' INSPECTION BY /DATE INSPECTION BY DATE 62 Z7 -Zil <br /> ! <br /> 2 H 1426 . Rev. 1-74 1=74 2M <br />