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SAN JOAQUIN LOCAL HEALTH DISTRICT ,' l <br /> FOE QFFICE USE: 1601 Hazelton Ave. , Stockton, Calle,*)D ;: felephone: (209) x+66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 8`k) <br /> 4 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct..-a ,., .. <br /> and/or install the work' herei-n 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} fi�� � CENSUS TRACT <br /> 7 <br /> Owner!s Name. `' / PA!C),�0��)'P •4 Phone <br /> k Am/vIAddress � � /�/ ( 7-/ City w/ <br /> Contractor's Name c?�' �-�� �? License ��37ghone � <br /> TYPE OF WORK ICheck) : NEW WELL DEEPEN /7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR'/-7 PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTl;C TANK EWER LINES PIT PRIVY' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPA9E CESSPOOL/SEEPPIT OTHER <br /> PROPERTY LI RIVATE;DOMESTIC WELL PUBLIC 'DOMESTIC'WELL <br /> INTENDED USE- -TYPE `OF WELL CONSTRUCTION SPECIFICATIQ11S <br /> —�rindustrial Cable Tool Dia. of Weill Excavation <br /> ..Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of.Casing <br /> Irrigation t,/ Gravel; Pack Depth of Grout Seal ' <br /> Cathodic Protection ✓ Rotary's Type of Grout 1 <br /> Disposal Other Other Information I9 <br /> GeophysicalSurface Seal Installed Bbsu <br /> ji <br /> Y: S <br /> PUMP INSTALLATION: 'Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: 17 State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth �- <br /> Describe Material and Procedure <br /> r I :'hereby agree to comply with all laws 'and regulations of the San Joaquin Local health Dlstri"ct <br /> and the State- of California pertaining to or .regulating well'-construction. Within FI1TE19i jbi S, ` <br /> after completion of my work on anew well, I will furnish the San Joaquih Local Health. District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in use. The 46ve• <br /> information is :-true to the-best of my knowledge, and belief. I WILL CALL FOR A GROUT IP(SPECTI(lN <br /> PRIOR TOG UTING AND A FINAL INSPECTION. <br /> t SIGNED TITLE <br /> „ <br /> (DRAW " PLAN 'ON iISE SIDE <br /> DEPAPTMENT USE ONLY <br /> PHASE I <br /> APPLICATION 'ACCEP B 9. �II�A�L� DATE <br /> ADDITIONAL OOMMMS: <br /> .PHASE If GROUT INSPECTION PHASE II FINAL INSPECTIO#'. <br /> INSPECTION BYDATE INSPECTION BY, DATEEr r fig+ <br /> E H 1426 h Rev. 1-�74-kc,1�-s:� �0 ' f'` &4- "vs�'"''�-�o�-�. '2 P� �-►�. � �'�-:, <br />