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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. tLJ�_G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ,pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> end/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 the San Joaquin Local Health District. <br /> _OB ADDRESS/LOCATION //a,?(^j ^ !t e- ,u CENSUS TRACT <br /> ^wner's Name //C't, ey, / Phone <br /> t7 <br /> `Address 6 sn� r <br /> city_2L.v 6!g'f'eo <br /> ontractor's NameAM- <br /> License o�2 Phone <br /> ffrS <br /> YPE OF WORK (Check) : NEW WELL / 1DEEPEN /% RECONDITION /7 DESTRUCTION /7 <br /> .- PUMP INSTALLATION /—/ PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other /7 — <br /> ISTANCE TO NEAREST: SEPTIC TANK!/onfi- 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 __L.<-eable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q .— <br /> _L:_ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information rn <br /> Geophysical Surface Seal Installed B rr^ F <br /> PUMP INSTALLATION: Contractor y4/H 61-ym4 <br /> Type of Pump ?ihc�iti✓� H.P. �2 <br /> PUMP REPLACEMENT: %/ State Work Done <br /> .dME' tREPAIR: / / State Work Done <br /> F—STRUCTION OF WELL: Well Diameter Approximate Depth <br /> _ Describe Material and Procedure <br /> T hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS_ <br /> 2'fter 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 /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> rIOR TO GR ING AND FiN <br /> ,MEE N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> '^PLICATION ACCEPTED BY �° ���/ DATE <br /> DITIONAL COMMENTS: e/ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> rNSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />