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N JOAQU.IN ,LOCAL HEALTH DISTR16 <br /> FOR OFFICE USE: 16E. Hazelton Ave. , Stockton, Ca if" . <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit' No.,�7 7- <br /> e-,,- <br /> e-,,- THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED Date Issued <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 appl.icati-on 'is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Hellth District. <br /> JOB ADDRESS/LOCATION -f l CENSUS TRACT <br /> Owner's Name L Z � _ --w_^-� Phone --- <br /> Address <br /> 4141`-f' 1 L�,4 � I �� � City <br /> Contractor's Name C -� � yj 7 �• License .: Phone 'Z45-;A07 <br />,TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION_/_/ DESTRUCTION /-] <br /> PUMP INSTALLATION / . / PUMP REPAIR / / FUMPRL'I'LACEMENT <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 /> Industrial Cable Tool Dia. .of Well Excavation /z <br /> J/ Domestic/private Drilled Dia. of Well Casing "�� (� _ <br /> Doiiestic/public Driven Gauge of Casing — <br /> Irrigation Gravel Pack Depth of Grout SeAl � ' <br /> Cathodic Protection Rotary Type of Grout r - <br /> Disposal Other Other Information'' - <br /> Geophysical Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor f <br /> Type of- Pump — — H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 we.11 'construc'tion. 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 nest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO G .OUTING AND A FIN L. INSPECTION. Q� <br /> SIGNED TITLE <br /> v <br /> (DRAW PLOT, PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 8Y DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT I SPECTION VPHASE III/FINAL I PECTION <br />,INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev- . 1-74 0497 _ 2M 1 <br />