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SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> FOR OFF ' USE: 1601. E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. O�d <br /> ` �! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �/ Z� /OC-1_ <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 hereinidescribed. This application is made in compliance with San Joaquin . <br /> County Ordinance No. 186�/a� the Rules and Regulations of- the San Joaquin Local Health District. <br /> JOB -ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone g' 2- <br /> i <br /> 1 � � <br /> Address 5 I �� o_`� p`� 7 city A--j7_0-C_-- <br /> Contractor s <br /> --j _0-e-----Contractor's Name 'j/.74Z_ License �� Phone`32 73� <br /> ✓� �'? , <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION fi�f_­PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /7'—/ �p � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY !M 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT iM OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia, of Well Excavation ? <br /> Domestic/private .l Drilled Dia. of Well Casing 1� <br /> Domestic/public 4 Driven Gauge;of Casing <br /> Irrigation :j Gravel Pack Depth of Grout Seal I� <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal 1 Other Other Information IM <br /> Geophysical Surface Seal InstalledlB : <br /> PUMP INSTALLATION: Contractor <br /> Type of :Pump 12 EerL1,(S iM H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Appr Lmate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well-constructions. Within_.FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin'MLocal Health District a ; <br /> TELL DRILLERS REPORT of the well and notify them before putting the well'din use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A FI AL. INSPECTION. <br /> SIGNED TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) IM <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY - - DATEadz -? - <br /> kDDITIONAL COMMENTS: t ;t <br /> PHASE II GROUT INSPECTION PHAS III/F11 AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1117 <br /> E H 14266 Rev. 1-74 II <br />