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/Jj J <br /> _ WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3y"Fl,-STocKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> �Tl <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT / 99 <br /> FOR OFFICE USE: �1601 E. Hazeltoa Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 2 p <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) -3-y-?3 <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 <br /> the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION n 0 p �. ��j (� �d �✓�� d� ,L� CENSUS TRACT <br /> a. Owner's Name ` O 2 �iyf[:C �1 Phone <br /> Address G U ✓ City <br /> `Contractor's Name r_ 12-w j License Ila5S977 Phone /{(�a/2/,:L <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /f / PUMP REPAIR / GMP REPLACEMENT <br /> Other /T r7 e ee <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool Dia. of Well Excavation <br /> .. 4,1_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Other Rotary Type of Grout <br /> Other Other Information <br /> 'PUMP INSTALLATION: ContractorY ., q <br /> Type of Pump ff , ,c, r 21A H.P. fig msµ• t <br /> .,,PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: LT,/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> rI 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 ru to the best y knowl dge and belief. / <br /> SIGNED ��„�.{�_ �j /' ` ) TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I > <br /> —APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G O N ION/ PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATEV INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 4/72 1M <br /> Pump Inspection D � Date l� ZZ/G ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth A <br /> COMMENTS <br /> PE SC Received Check#/ _ Amounl Date Permitl Invoice# Well 1D# <br /> Codes `�Info 8 as Remitted Service Re,,-est# <br /> W <br /> LR .U. � t� .�j` ( ,L <br /> MASTER WATER WELL PERMIT <br /> EHD 43-02-006 <br /> 12/6/2002 <br />