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J 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. 74D10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application id' he're'by made to the San Joaquin Local I€ealth 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. 1$6 and the R es' and Regulations of the San Joaquin Local Health District. <br /> - :Lll . <br /> JOB ADDRESS/LOCATION '/ 5�X-,E- Y4 AVE- 6A-je-- ppi <br /> cEUs T2-1G"T � <br />'Owner t s Na as^ / 49 �y -0 2 l2 <br /> Address--.�_ Z7 ©A:�=r �Ioz—` City i � <br /> Contractor's Name License 3 PhoZ9 9% ?— f <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /7 RECONDITION f-7 DESTRUCTION f7 <br /> E PUMP INSTALLATION PUMP REPAIR/-7 PUMP REPLACEMENT <br /> Other /% + <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 /> - INTENDED <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/private, <br /> Domestic/publiDriven Gauge of Casing <br /> Irrigation Gravel Pack- Depth of Grout Seal <br /> 'Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical <br /> Surface Seal Installed 'B <br /> s � <br /> PUMP INSTALLATION: Contractor <br /> Type .of;Pump H.P. . <br /> PUMP REPLACEMENT: • State Work Don <br /> PUMP .REPAIR'- � —"§ - ---,�S - .- <br /> // / tate Work Done <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 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- myknowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br />?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE t <br /> FOR J)EPARTMENTASE ONLY <br /> PHASE I f. ` <br /> APPLICATION ACCEP DATE �. <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASEZ14 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . bQ•-7 L # <br /> 6,7 <br /> _ A <br /> E H 1426 Rev. 1-74 L/75 <br />