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SAN J'OAQUIN LOCAL. HEALTH DISTRICT <br /> FOF:*`OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> ' - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-r <br /> , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `7f� <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 s.made in compliance with San Joaquin <br /> County Ordinance.ko. -1862 and the Rules and Regulations of Ne. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . S� CENSUS TRACT <br /> f <br /> Owners Name G,O Lt !S0 Phone <br /> Address <br /> City FC,4�o,� - -- <br /> Contractor's Name , LicenseS'f//L Phone 5 <br /> TYPE 'OF WORK (Check) : NEW WELL/V DEEPEN / / . RECONDITION / f DESTRUCTION /_7 f <br /> s� PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK/OZ�- SEWER LINES 060 + PIT PRIVY 4, <br /> SEWAGE DISPOSA��FIELD CESSPOOL/SEEPAGE PIT �.. OTHER <br /> PROPERTY LINE/ PRIVATE DOMESTIC WEL Q= PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> ' 'Industrial Cable Tool Dia, of Well Excavation � [n <br /> Domestic/private Drilled Dia. of Well Casing ►� T 1 <br /> Domestic/public, .;* Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic„Protection ._ Rotary._ - on .. .- ,Type .of Grout..- <br /> Disposal zr. Other Other Information <br /> Geophysical ` .Surface Seal Installed By: / ,i- S <br /> PUMP INSTALLATION:•._. Contractor <br /> Type of Pump , H.P. z S� <br /> ' t <br /> PUMP REPLACEMENT: / / State Work Done w t } <br /> PUMP REPAYR: - ,;, - --.� - -- - -. = - - :� .,,, _......Y; -,�._ ,...• ... �.,.fes <br /> / / State Worlc Done <br /> DES,TRUCTtON_ ;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 /> j 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 notif them before putting the .well in.use. The above <br /> information is true to the dbestf o� edgew-and -belief. . I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR.TO AND FINP <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> ! FOR DEPARTMENT USE ONLY <br /> t PHASEI I _- <br /> APPLICATION,ACCEP.TED-,-BX -- _ _' � `. DATE Z-45-- 7-7 . <br /> ADDITIONAL COMMENTS: <br />' y PHASE TI GROUT INSPECTION / PHASE /FIN INSPECTION <br /> INSPECTION BY DATE - 1Y - INSPECTION BY DATE <br /> ...E .H <br />