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r -Lo , !a � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> IM Telephone: (209) 466-6781 <br /> IM APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7`` P23,P <br /> f I� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ,,QJoaquin Local Health District. <br /> JOB ADDRESS/LOI�ATION ,.S" G ,S �e�L tee.& 1l/[ CENSUS TRACT <br /> Owner's Name �t Ca Phone <br /> Address City, <br /> Contractor's Name eall License #/D 7.hone ' �a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN 77—RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /� <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 (1 <br /> Industrial . ', Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well.Casing <br /> Domestic/public'" Driven" "" "" "'Gauge of Casing '"' <br /> Irrigation F Gravel Pack Depth of Grout Seal <br /> Cathodic-Protection Rotary Type of Grout <br /> G - Disposall' Other Other Information <br /> Geophysical Surface Seal Installed By:,_ <br /> PUMP INSTALLATION: Contractor -' <br /> �., Type of Pump H.P. '1_ <br /> PUMP REPLACEMENT: / State Work Done <br /> I PUMP .REPAIR: State Work Done a•-! � <br /> • �� <br /> ff <br /> k DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> iN <br /> I her.eby_.agree to comply •with all laws and regulations of the San Joaquin Local Health District <br /> and the Statellof 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 DRILLERS11REPORf`of the well and notify them before putting the .well in use. The above <br /> information is true to the best of my°.knowled beliLITLE <br /> I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING ANDA FINAL I SPECT SIGNED @�, _ _ <br /> �M D PLOT PLAN `ON R FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 9 <br /> APPLICATION- ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY. DATE INSPECTION BY DATE <br /> a i ' <br /> h 3/76 214 <br /> E H 1426 Rev. '1-74 <br />