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lam/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE. 1601 E.�.Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATIONIFOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�y-5Z2f/10 <br /> ,r <br /> THIS PEF,kT EXPIRES 1 YEAR FROM DATE °ISSUED Date Issued <br /> t (Complete In Triplicate) O� -- o�-0_ <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 /> JOB ADDRESS/LOCATION -�l -0-'a-e-r� J-��.c.- 1110 �, �.r. �rA, CENSUS TRACT <br /> Owner°s Name Phone Lsl �1 <br /> r � <br /> Address City <br /> Contractor's Name v, : .cam License #A 23 73 Phone3 c <br /> TYPE. OF WORK (Check): NEW WELL / / DEEPEN '/-7 RECONDITION /"T DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7PUMP REPLACEMENT <br /> Other /% — — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ._-P-ROPERT-Y LINE ---PRIVATE DOMESTIC--WELL m '�' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ot_Well Excavation <br /> Domestic/private Drilled. Dia. of We11 Casing <br /> ' Domestic/public , Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed BY: <br /> PUMP INSTALLATION: Contractor ),9ZZ25 - <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: r State Work Done <br />--PUMP-'.REPAIR:=-- "/'-/` State Work Done - <br /> ,RE&T.RUCTION 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 /> 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.knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTI �ANp A FIN& INSPE ION. <br /> SIGNED TITLE <br /> kMADRAW PLOT PLAN ON REVERSE SIDE r <br /> FOR DEMYMENT USE ONLY <br /> PHASE I 11 <br /> f <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL CONMENTS: <br /> PHASE II GROUT IINSPEjCTION PHASE III F NAL INSPECTIO <br /> INSPECTION BY /DATE/,47_ <br /> DATE !�Og8 TION BY T ^ <br /> } E H 1426 Rev. 1- 4 1-74 2M �� <br />