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SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> V <br /> F4R!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: {209) `46.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !4Z-�{O j;4 . <br /> THIS PERMIT EXPIRES.V 1, YEAR;FROM DATE ISSUED Date Issued <br /> (Complete .In Triplicate) 0&0—f— <br /> Application is hereby made to the San Joaquin Local stealth District for a peit to construct <br /> k and/or install the work herein described.. This. application is made in compliance with San Joaquin , <br />' County.-Ordinance..Mo-.,,1862land-the-Rules and, Regulations of the San Joaquin Local stealth District. <br /> AA-- <br /> JOB'ADDRESS/L. 00ATION <br /> JOB'ADDRESS/L. 00ATIDI3CENSUS TRACT <br /> Owner's Name Phone <br /> h Address �� R .. City . <br /> Contractor's Name- License # t�3 7 --- Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN. / RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR �� PUMP REPLACEMENT 1-T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT _ OTHER ! p <br /> - PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <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 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 4j. // <br /> jType of Pump e.r -✓ rA H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> ._.. A <br /> PUMP '.REPAIR: f State Work Done -,4u 4e <br /> ES-TRUCTION OF WELL: Well Diameter' Approximate Depth <br /> F 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 Ie an �elief. I WILT, CALL FOR:A GROUT INSPECTION <br /> PRIOR. TO- G TING AND A FINAL INSPE IO <br /> SIGNED MeLITLE <br /> D LOT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE X <br /> APPLICATION ACCEPTED BY � + <br /> ADDITIONAL COMMENTS: <br /> i PHASE II-GROUT INSPECTION PHASE III FINAL INSPECTION L <br /> ' INSPECTION BY: DATE INSPECTION BY —f> DATE <br /> 1 E H 1426 Rev. 1--74 1-74 2M <br />