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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHf FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Tom- SS 8�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - <br /> (Complete 'In Triplicate) 1 <br /> Application is hereby made toJthe 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 z CENSUS TRACT <br /> _ y � <br /> Owner Q s Name �� Phone � 3 �--- 'T��" S <br /> Address 120 city 7 <br /> Contractor's Name �� Q License # ��G GZ Phone ` LZ� 55-F <br /> t <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /_7 DESTRUCTION f7 !. <br /> PUMP INSTALLATION ] ] PUMP REPAIR /7 PUMP REPLACEMENT/7 a <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE'€DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V f <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 'Gf . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4 Domestic/private. i Drilled Dia. of Well Casing +�I <br /> Domestic/publicDriven Gauge of Casing Z 6 <br /> Irrigation ;i- Gravel Pack Depth of Grout Seal - - .�- -_-- <br /> Cathodic Protection it Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical �_ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: L 7 State;-.-Work Done <br /> PES-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. FIFTEEN4 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 true to the-best of my .knowledge` and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G 4TNp ANEQA KNAL INSPECTION. a <br /> SIGNED TITLE 119 .� �. <br /> r (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> i - -FOR DEPARTMENT USE ONLY <br /> PHASE I - <br />'r APPLICATION ACCEPTED -�BY - - "" W T `"' Y DATE 7¢ <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT MISPECTION s� PHASE IiI FINAL INSPECTION <br /> INSPECTION BY DATE //� 'i� % INSPECTION BYDATE <br /> '1 E H 1426 Rev. 1--74 1-74 2M <br />