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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,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 =,. <br /> (Complete In Triplicate) 7-/2-0 <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 He 1�th' 5327" E' , �istrict. <br /> JOB ADDRESS/LOCATION / m � JeI�Lkji2 CENSUS TRACT <br /> 1 <br /> � Owner's Name [., Phone <br /> Address 4> 21 < City 4,kAL212 <br /> y <br /> Contractor's Name � _ G"7'T Sis`hJ _ License &229n/p Phone - 7 <br /> , TYPE OF WORK (Check) : NEW WELL / DEEPEN"1% RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ :/ PUMP REPAIR 2X PUMP REPLACEMENT /_ <br /> Other J7 -- <br /> I <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 N. <br /> Industria] 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 /> j Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done' <br /> PUMP .REPAIR: <br /> /JC/ StateiWork Done D22 � <br /> DESTRUCTION OF WELL: Well Diameter ` y " Approximate Depth <br /> Describe Material and Procedure ? <br /> I <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 '-constructi.on. 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 notifythem before f <br /> putting the- well in use. The above . <br /> information is true to the best of my knowledge and belief. I WILL CALL 4OR A GROUT INSPECTIO <br /> PRIOR TO OUTING A FINAL INSPECTION. <br /> SIGNED TITLE ' <br /> DRAW PI; T PLAN 40N REVERSE SITE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION, ACCEPTED BY DATE' r d_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II ; INAL INSPECTT <br /> QN <br /> INSPECTION BY DATE INSPECTION BTIZeLkLZ DATE <br /> E H 1426 Rev. 1-74 376 2M <br />