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C7„ o G�G�v SAN JOAQUIN LOCAL HEALTH€ DISTRICT <br /> FOR;O - ICE USE. 1601 E. Hazelton Ave. , . Stockton, Calif. <br /> j er Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -Z�_ <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED DatE' Issued 7.-3o <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 Joaquit <br /> ,- County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONxf sZtad� CENSUS TRACT <br /> Ownera Name �- sz i GS`.I'6 Phone <br /> Address In City.: . 11-� <br /> Contractor's Name rm. License Q r- hone <br /> TYPE OF WORK (Check):. NEW WELL -17 DEEPEN /j7 RECONDITION I j DESTRUCTION /"7 <br /> PUMP INSTALLATION f_1/ PUMP REPAIR -F7 PUMP REPLACEMENT 1 <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'' PUBLICDOMESTIC WELL <br /> INTENDED USE. TYPE OF; WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia. ofWell Excavation p <br /> x Domestic/private Drilled Dia. of Well Casing r (� <br /> Domestic/public Driven ; -Gauge of Casing <br /> f 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 <br /> Type .af ,Pump .Su. a � /d H.P. .L <br /> PUMP REPLACEMENT: / /. S•tate'Work Done Nd� ,r1 G� � �� <br /> PUMP REPAIR: / / State Work'Done ^I. . . <br /> i DESTRUCTION -OF WELL: Well DiAmeter <br /> f 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 trite to the:best.of. my. knowledge and b ief. I WILL CALL FOR 'A GROUT INSPECTION <br /> PRIOR TO GROU ING'AND A I'INAL INSPECTIO <br /> SIGNED �. j` re k . ,ztf TITLE <br /> // W PLOT-,!PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br />, APPLICATION' ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: , 7. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> -INSPECTION BY DATE INSPECTION BY DATE r,.?- _ --7_ <br /> EH 1426 Rev. 1-74 = . v! It 17 c_ VU <br />