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` SAN JOAQUIR. LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S� <br /> (Complete In Triplicate) <br /> Lpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Jo4qui <br /> :aunty Ordinance No. 1862 and lt�he Rules and Regulations of the San Joaquin Local Health. District. <br /> 17) <br /> [OB ADDRESS/LOCATION / CENSUS TRACT <br /> NS Ib}v <br /> Iwner's Name fe <br /> r� t Phone <br /> L <br /> Lddress , lox 1 yL _ City t5T6_qKRk) <br /> :ontractor's Name � � ��� #�License 14 <br /> ��Z Phoneb2'm <br /> i <br /> :YPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION_/ / DESTRUCTION /_7 t 1zPUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT _/�i o <br /> �.�.�..... ____�..,..� .._O-cher_"/=J.�.�,----- _ ..�.�._ ..-_..,—._�_.._� . .�.�. - � ,•..,. <br /> I �{ <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES (} PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INT ED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> dustrial Cabld"Tool Dia. of Well Excavation <br /> Domestic/private r� (Drilled Dia. of Well Casing kto t <br /> Domestic/public �� DriveGauge of Casing Q = s <br /> Irrigation vel` Pack Depth of Grout Sealis- <br /> to <br /> Cathodic Protection Rotary Type of Grout� <br /> Disposal Other Other Informatibn `- L <br /> Geophysical Surface Seal Installed By: i <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> ,ES.TRUCTION OF WELL: Well Diameter 1 (r 'App1raxiUEe Dept 471. <br /> Describe Material and Procedure T <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating� ell-constr. t'.' Within FLFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San• �oaquin Local Health District <br /> TELL DRILLERS REPORT of the well and notify them before putting the..wellrin use.. The-labove <br /> _nformation is e t the best of my knowledge and belief. I WILL CALL,-' FOR A GROUT INSPECTION <br /> RIOR TO G 0 A FINAL INSPECTION. <br /> iIGNED TITLE 6 L6 �3 <br /> s: Y...�_. __ (DRAW..ELOT_P-i ANONREVERSE_SIDE.). - - - — -- j <br /> FOR DEPARTMENT USE ONLY x <br /> 'RASE I <br /> IPPLICATION ACCEPTED BY DATE <br /> LDDITIONAL COMMENTS: ! <br /> PHAS II GROUT INSPEC N PHASE III/FINAL INSPECTION <br /> INSPECTION- By ,Z DATE K INSPECTION BY DATE M <br /> 1 !77 Par <br />