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�a.fa SAN JOAQUZN LOCAL HEALTH DISTRICT <br /> j FO&I0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> in <br /> Application is hereby made to the San (JoagquineLocal rHealth 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION F a 4e lam( CENSUS TRACT Q 5 <br /> Owner's Name <br /> do!d r Phone <br /> Address _ Y L 7' (.r)e%� .JA .� D City ��yti G sgvT\� <br /> Contractor's Namp ay License /f <br /> s 3 7 hone Y C7( <br /> TYPB OF WORK (Check); NEW WELL / DEEPEN/7 RECONDITION /� DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /f <br /> Other/% <br /> DISTANCE TO NEAREST: SEPTIC'TANK <br /> AL FIELDER LINES PIT PRI <br /> SEWAGEiDISPOSTJY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia, of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing 6 <br /> Domestic Driven <br /> ig <br /> Trzationublic Dr <br /> \ i \ Gauge of Casing �. <br /> 1 Gravel Pack Depth of Grout Seal <br /> CathodiCProtection `71 Rotary Type of Grout <br /> Disposal ' t Other Other Information <br /> Geophysical 1( Surface Sea1_ Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y, H.P. <br /> PUMP REPLACEMENT / / SItate Work Done <br /> PUMP:REPAIR - /�� Spate Work Done / <br /> .s� [.E iCp_y��,y - <br /> pESeRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 i <br /> after' 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 /> information is true to the"best of my-knb le gAliefkI WILL CALL FOR"A"GROUT INSPECTION <br /> PRIOR TO ING AND FINAL ION. 1 <br /> SIGNED <br /> TLET SIDE <br /> PHASE I — <br /> �� J - EPARTMFNT USE ONLY <br /> -. ;/} <br /> APPLICATION ACCEPTER DAA <br /> A�IONAL COMMENTS: <br /> PHASE IZ ROUT INSPECTION <br /> INSPECTION BPHASE III/FINAL INSPECTIO�y` `�— <br /> Y DATE _� INSPECTION BY RATE 9 / <br /> E H 1426 Rev. 1-74 <br />