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f .SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave-. , ,Stockton, Calif. <br /> k' <br /> Telephone: (209) 466-6781 �� .,, ' <br /> L APPLICATION~FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. G ,5� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued0- <br /> t (Complete In Triplicate) <br /> Applicatidn 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 .Joiquir <br /> k County Ordinance No. 1862 and the Rules nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ON / 6S� V 6 -C1 f� CENSUS TRACT <br /> Owner's Name Phon <br /> Address fzv� y ! '��' Ci <br /> i Contractor's Name' License/4"? 3 Phone44` <br /> c-� r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 . <br /> K _PUMP INSTALLATION /P/ PUMP REPAIR / / PUMP REPLACEMENT /_7 6` <br /> r.. 1 / / <br /> ? Y Other Ts <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL E'er PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL +. CONSTRUCTION SPECIFICA I S <br /> Industrial ^' Cable Tool Dia, of Well Excavation A. <br /> tfDomestic/private '# Drilled Dia, of Well Casing IV P <br /> Domestic/publ-fie" - "`Driven Gauge of-Casing -- <br /> Irrigation l a Gravel Pack Depth of Grout Seal v' <br /> Cathodic Protection t/Rotary Type of Grout <br /> Disposal � Other Other Information <br /> Geophysical F , ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor � •. � <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: , / / State Work Done <br /> •'� .kms <br /> t <br /> DES-TRUCTION 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 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- Healthl.Distriet <br /> WELL DRILLERS REPORT of. the well and notify them before putting the well in use. , 'The above +,, <br /> information is true to the best-of my knowledge and belief. I WILL CALF FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION._ <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ?OR DEI_ARTMENT USE ONLY <br /> PHASE I , , <br /> r APPLICATION ACCEPTED - ,s.e DATE <br /> ADDITIONAL COMMENTS: , <br /> PHA-0 IJ ROUT. INSPECTI PHASE /FIN NSPECTION <br /> INSPECTION BY �� DATE INSPECTION BY DATE -7 <br /> /Vo /ael /.a z-3/7� 1177 . .. "-2M <br /> 'no-A'g,_ . E H. 1426 Rev. 1-74 ) (0 o'/caQ�J` _ _ <br />