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C ,, d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFF CE USE: 1601. E. Hazelton Ave.. , Stockton, Calif- <br /> Telephone : (209) ,466-67$1 7 :y1 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�J <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 /> JOB ADDRESS f LOCATION �v �- -- CENSUS TRACT, s <br /> Phone <br /> owner's Name B , • iE � . <br /> City <br /> Address <br /> Contractor's Name <br /> License # Lf 3 Phone �6 <br /> _ yy <br /> e WELL / / DEEPEN/_,/ RECONDITION / DESTRUCTION / T <br /> TYPE OF WORK. (Ch ck} NEW _ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other - <br /> e <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 /> 4 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ECable Tool Dia. of Well Excavation <br /> Industrial <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public s Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic ,Protection 1 Rotary s Type of Grout <br /> Disposal # Other Other Information <br /> Geophysical i _ Surface Seal Installed By: <br /> - y ti• a�F l/C� — <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> I v ; <br /> 4 PUMP REPLACEMENT: / / State Work Done <br /> k PUMP REPAIR: <br /> State Work Done <br /> � �.� <br /> 4 <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> r'- 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 kno ledge and--b lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO AND A INAL I N 5BB9XZ94,. <br /> I TITLE <br /> SIGNED �a . - --- <br /> (DRA PL T-P AN ON VERSE SIDE) <br /> DEPARTMENT. :QSE ONLY <br /> PHASE I I <br /> DATE c�� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p I /FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> } INSPECTION BY. DATE <br /> �, 6/77 <br />