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10/15/2003 11:16 464013B ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r.. <br /> FM OFftCE USE 1601 E. Hazelton Ave., Stockton, Calif. <br /> 4' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 .3r yk� <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �t <br /> (Complete In 'triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to Conatruet <br /> nd/or install the work herein described. This application is made in compliance with San Joaquil <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION ¢epA& an a"d , CENSUS TRACT <br /> wner's Name b 'V Phone �•. G Q3 <br /> ddresa City <br /> ontractor's Name License d /Phone F ;.F 7T2a <br /> YPE OF WORK (Check): NEW WELL DEEPEN /-J RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION L/ PUMP REPAIR /� PUMP REPLACEMENT !-T <br /> Other / 7 <br /> ISTANCE TO NEAREST: SEPTIC TANK 146L SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLICDOMESTIC WE <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIOL1,NS C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing /y �� <br /> Domeatic/public Driven Gauge of Casing m pl9u 1✓ R <br /> y Irrigation, Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout P eti <br /> Disposal - Other Other Information <br /> _Geophysical Surface Seal Installed By: 91- •^r. ese.�- e� <br /> tW7 INSTALLATION: Contractor H.F <br /> Type of Pump <br /> UMP REPLACEMENT: / / State Work Done <br /> UMP '.REPAIR: _/7 .State Work Done <br /> ESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .fter completion of my work on a new well, I will furnish the San Joaquin Local Health District t <br /> FELL DRILLERS REPORT of the well and notify them before putting.. the well in use. The above <br /> nformation is true to the beet of my knowledge and belief. T WILL CALL FOR A GROUT INSPECTIO <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED TITLE <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ,HASE I <br /> DATE <br /> YPLICATION ACCEPTED BY <br /> .DDITIONAL COMMENTS: <br /> PHAg II R INSPECTION P II WCZ INSPECT <br /> :NSPECTION BY DATE - INSPECTION BY/ DATE <br /> L/7C 7M <br />