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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 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 /> fE <br /> THIS PERMIT EXPIRES .1. YEAR FROM DATE ISSUED Date Issued7a <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 HealthDistrict. <br /> ' <br /> SS4 <br /> .ems ENSUS TRACT <br /> JOB ADDRESS/LOCATION p o <br /> Owner's Name /fZ Q7 S Drc.J Phone b <br /> Address City <br /> / ti Cs7 !„�-�6 L,r <br /> Contractor's Name l License #/ <br /> �, Phone <br /> TYPE OF WORK (Check) : NEW WELL -/—/ ' DEEPEN /? RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other14 QW-1 <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 I 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 Sur a Seal Installed BY: <br /> �. PUMP INSTALLATION: Contractor . <br /> _ H.P. .Sa <br /> Type of Pump <br /> a E c • <br /> PUMP REPLACEMENT: . / /+ State.Work Done r <br /> PUMP :REPAIR: - �/ State Work Done - - <br /> ' Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree with all laws and regulations of the San Joaquin Local Health District . <br /> and the Stat of Califor a pertaining to or regulatingjwell•construction. Within FIFTEEN DAYS <br /> i after comp tion of my wo k on '`a new well, I I furnish the San Joaquin Local Health District <br /> WELL DRIL RS REPORT of 'e well a f th before putting the -well in use. The above <br /> informati n is tru to be a l ge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO ROU A IN I <br /> ► <br /> TITLE <br /> SIGNED <br /> yy . 6i. PLAN ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL f;OMMINTS: ZZ <br /> PHASE II OUT I PECTION PHASE III/FINAL INSPECTION J <br /> k INSPECTION BY DATE INSPECTION BY DATE 11119176 <br /> 3/76 2M <br /> � _E H 1426 Rev. 1-74 <br />