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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA.OFFICE USE: 1601 E. Hazelton Ave. 'Stockton, Calif. <br /> . <br />' <br /> .Telephone Y ,(209) 466-6:781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -.5-7 <br /> 214.1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> Date Issued <br /> j t (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 JoaquinI <br />.County Ordinance No..� 1862 andIthe Rules and Regulations of the San Joaquin Local Health District. <br />'- <br />'JOB ADDRESS/LOCATION <br /> CENSUS TRACT ' <br /> Owner's Name Vk • ! l� �d ? � � <br /> Phone J Z <br /> Address <br /> 9 City <br /> Contractor's Name <br /> lel iT ! Iv�v .License # 76602 Phone z74 f <br /> SJ <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN _ <br /> _/ / RECONDITION /_% DESTRUCTION /_7 <br /> . PUMP INST LATION _/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /? <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES <br /> -76'-,,.SEWAGE DISP05 L FIELD 0,L PIT/SEEPAPRIVY <br /> PROPERTY'LINE - PRIVATE DOMESTIC WaPGTHER <br /> � C DOMESTI� WELL <br /> Industrial <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAS <br /> �, Cable Tool Dia. of Well Excavation <br /> TION <br /> Domestic <br /> /private �, Drilled Dia. of Well Casing ! <br /> Domestic/public, Driven Gauge of Casing Z <br /> Irrigation Gravel- Pack Depth of Grout Seal <br /> Cathodic Protection <br /> - � �. Rotary Type of GroutDisposal - '"" Other Other Information h sical <br /> ' <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> ,,� ,Contractor � <br /> 4. .. <br /> -1- 'Type of Pump <br /> PUMP REPLACEMENT: k <br /> State Work Done 4 <br />?UMP''REPAIR:_ ` <br /> State Work Done <br /> LEESTRUCTION OF+FELL: Well `Diameter <br /> > ' + <br /> ;Describe Material and Procedure Approximate Depth <br />: .hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />,nd' the ,State of' California pertaining to or .regulating well "construction. <br /> iter completion ofmy work on fa. new well I� Within FIFTEEN DA'S <br /> ai11 furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the`�well anal notify them before`putting the well in use. The above <br /> nformation is ,true to the best of my knowledge and belief. I <br /> RIOR TO R TI NAL INSPECTION. WILL CALL FOR A GROUT INSPECTION <br /> _ , t <br /> IGNED 1 i ` <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ` FOR DEPARTMENT U5E ONLY <br /> RASE I a. _�' � . . . . s <br /> PPLICATION A <br /> CCEPTED BY <br />)DITIONAL COMMENTS: 't�' ' ! DATE (��-��� <br /> t <br /> PHASE II ROT SPECTION <br /> 45PECTION BY PHASE III/FINAL INSPECTION <br /> '� DATE .� INSPECTION BY <br /> DATE `e' Z -7 <br /> E H 1426 Rev. 1-74 ._ Q/_ -J' , ��7 <br />