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G 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. »mfr <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _/d-lam <br /> (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 Joaquinf <br /> County Ordinance No. 1862 and' Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( /A 4)27 6 CENSUS TRACT <br /> Owner's Name 7553 <br /> Phone -R <br /> Address 3 -17 ail, � D dl i? o�J" l�i City i0 0-�j <br /> Contractor's Name License 7%01t7 Phone X07 <br /> t , <br /> TYPE OF WORK (Check):f, NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION:/? <br /> �,PUMP INX TALLATION / / PUMP REPAIR PUMP REPLACpfifENT- /7 <br /> Other � <br /> ✓� / ,C f'.-�d 4 4, 1 ��� 7l a�e r^n �F �L i✓r�vF I <br /> DISTANCE TO NEAREST: ;SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> <'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 'OTHER � I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool ` <br /> Domestic/private Dia._ of Well Excavation, <br /> t Drilled Dia, of Well Casing > <br /> Domestic/public t Driven <br /> _ Gauof Casing <br /> Irrigation Gravel Pack. ge Depth of Grout Seal E111 <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal _ t Other _ —_Other_Tnformation, <br /> Geophysical Surface Seal Installed By: <br /> - --� <br /> PIR+lp INSTALLATION: Contractor <br /> Type 6k Pump H.P. - � <br /> ?UMP REPLACEMENT: / / State Work Done <br /> "PUMP':REPAIR: __^--"^'/�f" State Wolk Done "' - - T """� / / / <br /> .�c*' i �/�/ �• -� jt 1 S, P 7elY lt4'G iii <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth I <br /> Describe Material and Procedure <br /> I hereby agree to comply withgall 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 j <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District .a j <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND FIN ;INSPECTION. -- <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDF)1 <br /> PHASE I �FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY •`7�06/� - �4?^ DATE <br /> ADDITIONAL COMMENTS: t �• �Z <br /> PHASE II GROUT INSPECTION PHAS II ' F l L INSPECTION f <br /> ECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M y <br />