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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., -�7 ,jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 <br /> (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �` ]� CENSUS TRACT <br /> h ' <br /> Owner's Name ✓ aaf 0" Phone <br /> Address 3 ejo� S .a Cityc -�r� <br /> Contractor's Name C License #1J1,3�11--Phone E -LG 4 <br /> Ll <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN :/—/ RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTLATION REPAIR />e/ PUMP REPLACEMENT / <br /> AL <br /> Other <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing (d <br /> Domestic/public Driven Gauge of Casing <br /> 1C Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done itr­, <br /> PUMP .REPAIR: j/ State Work Done * 7J e,-.N0*J1 <br /> DESTRUCTION 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 kn ledge�7— d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS 0 . <br /> SIGNED, �G - TITLE ► .� _ <br /> bar <br /> W, T PLAN ON ERSE SIDE) ru.t : <br /> , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ;14E04IN09CTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY TE INSPECTION BY �P _ DATE .2 ad' 7 <br /> �:. 3/76 2M <br /> E H 1426 Rev. 1-74 <br />