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► I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE T SE: 1501 E. Hazelton'Ave`., Stockton, Calif,. <br /> t. Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ' <br /> and/or' install the,vork eln des ibed. This application ;is -made in compliance with San Joaquin, <br /> County Ordinance No. 62 and the R es and Regulations of the San Joaquin Local Health District. <br /> // z.q <br /> JOB ADDRESS/LOCATIO .� ®• CENSUS TRACT , <br /> Owner?s Name Go �6 f Phone <br /> Address City 4,00, <br /> ( t <br /> Contractor s Name - - <br /> � _ License"#� 2X'Thone y�7,0 76 t <br /> �.. <br /> TYPE OF WORK' (Check): NEW WELL �/ DEEPEN f_/: ,RECONDITION j / DESTRUCTION /_7 <br /> PUMP INSTALLATION /Xy PUMP REPAIR /---/'—PUMP REPLACEMENT <br /> Other 1 ,/,/- <br /> E <br /> -j t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SE A'GE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER P <br /> PROPERTY LINE - PRIVATE DOMESTIC '�LL - PUBLIC DOMESTIC WELL A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public fi. Driven 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 .' Surface Seal Installed By: <br /> PLjMP INSTALLATION: —Contractor-` <�6)_. ,_l-P .... . <br /> Type of Pu -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PNM' -R : /k/ State Work Done <br /> A <br /> DESTRUCTION_ OF WELL: Well -Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> 1 -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 w0_11-construction. Within FIFTEEN DAYS <br /> after completion of my work on a neva 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 knowledge aid belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE N, <br /> SIGNED ,. z'6kITLE r <br /> (D PLO PLAN ON RS <br /> E SIDE} a <br /> �/� R DEPARTMENT USE ONLY I� <br /> PHASE I <br /> APPLICATION ACCEPTED BY 9 DATE <br /> ADDITIONAL COMMENTS: + <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY T DATE / _ i <br /> E H 1426 Rev. 3-74 o/7.7 _ 21 <br />