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. Jay SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> BOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7> <br /> I <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 Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name HickeubothemPhone <br /> Address 4.a30 Leonlirdini - - - - _ City Stockton <br /> Contractor's Name j rel :QT Cr. N6aek r _8ori snc'-- - �_ License ` Phone q48-8817 <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN '/ / RECONDITION /7 DESTRUCTION /7 i <br /> PUMP INSTALLATION /X/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other I 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing W <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 <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Zler, G. Roack & Son <br /> Type of Pump H.P. 2 <br /> PUMP REPLACEMENT: Fl- -JS tate—Work_Dane <br /> '1 <br /> PUMP .REPAIR: / / State Work Done <br /> I <br /> DESTRUCTION 'OF WELL: ` Well Diameter Approximate Depth <br /> 'Describe Material and Procedure ; <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dfstri.ct <br /> and the State of California pertaining to or regulating well'construction. Within FIBTEEN 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 alidve <br /> information is� true to the best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION..' <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> ! (DMW P PLAN 'ON UEViRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e �. DATE / -/o. -K7 <br /> ADDITIONAL COMMENTS: 3 <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INBPECTIOAi BY DATEr, INSPECTION BY DATE <br /> E H 1426 Rev. '1-74 <br /> ,. •.' � 3176 2Kr,, <br />