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rte' <br /> SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> `FOR OFFICE USE: /1601 E. Hazelton Ave., Stockton, Calif, <br /> Telephone: (209) 466-6781 4 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ -3,13 ,r <br /> //THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ` (Complete In Triplicate) <br /> Application is dereby 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 Joaquii <br /> County Ordinance No. 1862and the Ru <br /> and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Q. <br /> Owner's Name . f3- Phone <br /> city- <br /> Address � .�-�✓_s <br /> Address -4— ,Yy <br /> Contractor's Name '� CYW License # Phone �.f i <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /-7, DESTRUCTION <br /> +' PUMP; INSTALLATION / / PUMP REPAIR / / PUMP ,REPLACEMENT A . <br /> Other <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE :PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTI WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ',Cable Tool Dia.--of.,—Well Excavation <br /> Domestic/private Drilled Dia. ofiWell Casing <br /> Domestic/public Driven Gauge` of Casing <br /> Irrigation ! Gravel Pack T� -Depth -of Grout Seal <br /> Cathodic Protection } Rotary. ' i Type of Grout . <br /> Disposal i Other i ... Other Information <br /> Geophysical Surface Seal Installed By: <br /> . 1 <br /> PUMP INSTALLATION: Con ractoref'� .� <br /> -Type-of._Pump M, . -�1, _ - -H.P. 7 <br /> i <br /> SateY <br /> PUMP REPLACEMENT: Y -�� <br /> PUMP -REPAIR: i_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ t <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 <br /> WELL DRILLERS REPORT of the well and notify them beforeputting the ye in use. The above <br /> information is true to thelbest of- my knowledge and belief. I WILL' CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO-UTING AN NAL INSPECTION. <br /> SIGNED tid TITLE <br /> C �J <br /> (DRAW PLOT, PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE It: <br /> APPLICATION ACCEPTED BY G✓ DATE -I�� - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FTN INSPECTION <br /> INSPECTION BY DATE INSP�ION BY ATE -Z9-�- <br /> 177 'Al <br /> E H 1426 Rev. 1-74 ' <br />