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60#hep� � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.NOFFICE USE: 3601 E. Hazelton Ave. , Stockton, Calif. <br /> • `F. Telephone: (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z12-301P } <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued , 57( <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. 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 /> JOS ADDRESS/LOCATION e- e�'IfA&e CENSUS TRACT <br /> Owner's Name ea Of Phone <br /> Address / �3/ ... r� -~ City . . <br /> Contractor's Name S e 0��.�" License l A3.7"-Phone -7.1-2 <br /> . TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/-7 RECONDITION /-T DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR/-7—PUMP REPLACEMENT f? <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t 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 (1 <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 /> I Disposal Other Other Information " <br /> ` Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: ContractorVM <br /> Type of Pump -04 !ter-`e it H.P. - <br /> PUMP <br /> .P.PUMP REPLACEMENT: . / State Work Done r?4.410 r.0 d/Z - r <br /> PUMP :REPAIR: —/7 -State Work Done' <br /> DESTRUCTION OF WELL: Well. Diameter 2 Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San J,oagiiin- Local Health,.District <br /> c -and the State of California pertaining to or regulating well`construction. :Wi. ki,F.IFTEEN DAYS <br /> after completion of my work on a new well - I wi1i iq:Fr&-t "t- Joaquin Local Health District a <br /> WELL.DRILLERS REPORT of the we�, and notify, t�►em,_ efare putting-the..well. in:use..: The above <br /> information- is true to the•beso :.my ow a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,PRIOR ,Ta-GROUTING AND A VfNAI�:d'NS E I <br /> SIGNE1V---TITLE <br /> DRAW LOT .PLAN 0 VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FXNAL INSPECTION <br /> 1 .INSPECTION BY DATE INSPECTION BY , <br /> DATE 7-`703- -4 <br /> r <br /> E H 1426 Rev. 1-74 5 2M <br />