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`�'Zf% ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT -'OFFICE USE: 1601 E. Hazelton Ave Stockton Calif. <br /> FO&� Ave. , , <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 .�1P�7`f <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 "" N CENSUS�TRACT ; <br /> Owner's Name o4. j'�7� Phone <br /> Address CJrl r City <br /> Contractor's Name � � _115 Licens./4` 1573 Phon&Cg416 ' <br /> TYPE OF WORK (Check) : NEW WELL/-T DEEPEN -/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR ,/_7 PUMP REPLACEMENT <br /> Other /� 1 <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 d <br /> Industrial Cable Tool Dia. of Well Excavation .S> i <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 Type of Grout ' <br /> Disposal Other Other Information } <br /> Geophysical + Surface Seal Installed By: <br /> F <br /> PUMP INSTALLATION., Contractor - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Donee <br />--PUMP-:REPAIR: <br /> ,?ESTRUCTION 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> �� �-'._�n - - - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i <br /> E : • '� ! � . FOR DEPARTMENT USE ONLY <br /> PHASE I `� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: " <br /> =PHASE 4I'+GR0UTstINSPECTION PHASE- III/FINAL- INSPECTION <br /> INSPECTION BY ' 'DATE INSPECTION- BDATE <br /> 'tt E H 1426. <br /> Rev. 1-74 1-74 21, <br />