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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOR,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 g-/3 <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 Jonq <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> 1(-13 S. G tLtu.t �,,I OK kbSc� ti is . /73 - 290-P/a <br /> JOB ADDRESS/LOCATION /� I/1(�p ]dg �/ 'De44 ),k Rd, o freE/1 CENSUS TRACT <br /> , <br /> Owner's Name s n /2 ✓.f"1,9 , Phone <br /> Address S71b 2K V&;X City <br /> Contractor's Name 4,rl 01// License 0 tf 7��hone 6 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION /-7 DESTRUCTION rJ <br /> PUMP INSTALLATION PUMP REPAIR ? 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 <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ` rSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractordv� � t�y <br /> Type of Pump �.� <rt/e] _ A.P. -30 <br /> PUMP REPLACEMENT / / State,Work Done <br /> PUMP .REPAIR: State Work Done 44_4n.Y\ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> o 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting.the_well in.use.._ .The above <br /> information 1s true to the best of-my. knowled go belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AIJD A FINAL INSPECTI N. <br /> SIGNED ITLE 0, / ce <br /> (DXAW ZLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' 4214 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE V /Y 7/6 <br />