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s ,v�i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB4OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 'I Telephone: (209) 466-6781 <br /> di APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES1 YEAR FROM DATE ISSUED Date Issued <br /> d (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 Joaquin <br /> County Ordinance No. 1862and the Rules and Regulations of the San Joaquin Local Health District.j <br /> pp .I <br /> JOB ADDRESS/LOCATION oZl CENSUS TRACT <br /> Owner's Name Fr2 6C Q Phone - 7J��3 <br /> Address ��ln> 1�3+7 2 - CA1C9: �'L"-, 0,-1 /��� City <br /> Contractor's Name /cJ/•� � � J License #i 2 7'•Z)Phone 0� <br /> it- <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /jC/ PUMP REPAIR /7 PUMP REPLACEMENT I f <br /> OthesS, <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 /> iIndustrial p_ i Cable Tool ti 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 qType of Grout \\ <br /> Disposal Other Other Information V <br /> Geophysical Surface Seal Installed BY: <br /> I PUMP INSTALLATION: Contractor a/. V�( t 4 Zl{fin/ i <br /> Type';.'of Pump— � T H.P. <br /> . <br /> PUMP REPLACEMENT: / / State Work Done <br /> ! ; ; _ - - <br /> PUMP'REPAIR: /7 State Work Done <br /> , t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth \ <br /> 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 wail^furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewellin use. The above <br /> information is true to the of my knowledge and belief. I WILL CALL F -, GROUT INSPECTION <br /> PRIOR TO GR UTING AND FINAL INSPECTION. /� <br /> SIGNED `- 1 TITLE -61 ? � <br /> ` � o� (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEP T USE ONLY - <br /> PHASE I- "� G/ <br /> ! APPLICATION ACCEPT AU/�rOTI DATE / - 7k <br /> OADDIITIOXAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE II F,1NAL INSPECTIO��N' <br /> INS�� <br /> PECTION BY ]DATE INSPECTION HY / DATE <br /> E H 1426 Rev: 1-74 .'rl I-74 2M <br />