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_ ;. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> —FO R!,OFT;. ;, USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> ` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2f2-- Z'zo .-10 <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 Joaquii <br /> " County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION JCENSUS TRACT <br /> Owner's Name Phone <br /> Address City�jQ,���- <br /> Contractor's NameE License #Q6 ,Phone <br /> TYPE OF WORK (Check) -. NEW°WELL / / DEEPEN/ / RECONDITION &< DESTRUCTION /-7 <br /> PUMP-INSTALLATION,../-/.. PUMP-REPAIR.,/•_/ REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES PIT PRIVY _ --- ---- 10 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 1 OTHER ; <br /> PROPERTY LINE,---.PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 9` CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ' Dia. of Well Excavation _ p <br /> Domestic/private `Drilled" Dia. of Well Casing E <br /> Domestic/public Driven Gauge of. Casing <br /> { Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protecti_6n Rotary Type of-Grou.t,_ <br /> Disposal ► Other r' Other' Information <br /> r �. <br /> Geophysical + Surface--Seal-Installed �By: <br /> PUMP INSTALLATION: Contractor "'""' . <br /> ,Type of Pump �, H.P. <br /> 1l. <br /> PUMP REPLACEMENT; # State .Work Dane <br /> PUMP .REPAIR: /� /' State 'Wor-k"`.Done <br /> DESTRUCTION OF WELL: , eApproximate Depth j} <br /> ll Diameter 4/ .� // � � <br /> - - :, <br /> k za <br /> Describe Material and-&rbcedure. <br /> -- P1 <br /> ' I hereby agree to comply with all laws and regulations of- the-San Joaquin Local Health District <br /> re <br /> and the State of California pertaining to or regu�lating�well "co nstrruuction-. Within FIFTEEN DAYS <br /> after completion of my work-o a-new-well,-I:will�f.urnisl--thi-San4oaquin Lrocal He-ai-t•h-District a <br /> WELL DRILLERS REPORT of the well and notify them before putting;the. wefl .in use. The above <br /> information is true to the best o my knowledge .zind.b`elief.'a�I- WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTIN D I AI, S- ECT ION.-- _- <br /> SIGNED ? TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE' II' GROU , INSPECTION f PHASE III/FINAL N PECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H__142f-- Rev- 1-74 -- ��,�77 _ 2M <br />