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NVMOO <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T1'l)F. OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> -'� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> —� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> .application is hereby made to the Sar Joaquin Local Health District for a permit to construct <br /> and/or install the work herein descriued. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 ^nd the Rulers and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION/21�zj CENSUS TRACT _-Aje-___-_ <br /> Phone <br /> Owner's Name <br /> �!7 3s2 ,� Q j i,•,r�/ City <br /> Address <br /> LX- <br /> License l! Phone <br /> mn <br /> Contractor's Name )Ar_�,;,■t; n & 1m �Lh�t� G`� = _ 3 <br /> TYPE OF WORK (Check) : NEW WELL _& DEEPEN /� RECONDITION /_7 DESTRUCTION /PUME REPLACEMENT=T M <br /> PUMP INSTALLATION / / PUMP REPAIR /� <br /> ' Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _CZ _ SEWER LINES PIT PRIVY �p <br /> SEWAGE DISPOSAL FIELD �.� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVAT% DOMESTIC WELL --- PUBLIC STIC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> of Well Excavation <br /> Industrial Cable Tool Dia. �\ <br /> �- Domestic/pyivate Drilled Dia. of Well Casing 11 <br /> .y Domestic/pfublic Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation �_ a of Grout <br /> Cathodic Protection Rotary TypOther Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed B <br /> P11MF INSTALLATION: Contractor H.P. <br /> t Type of Pump <br /> PGMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES.T UC N OF WELL: Well -- -- <br /> Approximate Depth <br /> - �� <br /> escribe Mat r al and Procedure <br /> I he agree to comply with all laws an re�tions therict <br /> an oaqui L 411thinaFIFTEENtDAYS <br /> and the State of California pertaining to or regulating well 'construction. <br /> efter completion of my work on a new well, I will furnish the San Joaquin Local HeThehaDistrict <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND INAL INSP CTION. TITLE <br /> SIGNED W PLOT PLAN ON REVERSE SIDE) <br /> YS' <br /> Z <br /> DEPARTMENT USE ONLY L" <br /> PHASE I /ZZZ- <br /> DATB _ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CO : PHASE III FINAL INSPECTION <br /> P S I GROU INSPECT10N <br /> INSPECTION BY DATE INSPECTION BY _ DATE k,Y, <br /> 224 t / <br /> E H 1426 Rev. 1-74 <br /> M94 <br /> ..-. <br />