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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27--fti— <br /> THISiPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q-T 7 <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 herein1described. 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 � �� d-c.E.�-� els _ CENSUS TRACT <br /> Owner's Name Phone <br /> Address ( ` " =� 1� � 6 city <br /> Contractor's Name License # Phone Q ' <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN :/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT + <br /> Other <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 j <br /> Domestic/private Drilled Dia, of Well Casing.s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation" L. Gravel Pack Depth of Grout Seal j <br /> Cathodic Protection I Rotary Type of Grout ..4 <br /> Disposal Other Other Information W <br /> t <br /> Geophysical, Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor` F,,�a � - '' rte-; f O 1 <br /> Type of Pump `�-' � . i.�la�� H.P. <br /> PUMP REPLACEMENT: % .,/ } State Work bone <br /> Al <br /> PUMP .REPAIR: I ' / / State Work Done <br /> DES•TRU_CTIO_N OF WELD: 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 Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the wellin use. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION 1 <br /> PRIOR TO GR0UTING4n/A-)FINAL INSPECTION. <br /> SIGNED 'mow>c. 'J �. �- TITLE <br /> x ( (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I $ <br /> APPLICATION ACCEPTED BY DATE O <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S /FIN INSPECTIO <br /> INSPECTION 'BY DATE /✓ INSPECTION BY DATE <br /> ' hj <br /> Al <br /> E H 1426 Rev. 1-74Ltfn !. C�, � - C SC <br />