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f ,,.SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�rO ; ICE U x_1601 E. Hazelton Ave. , Stockton, Calif. ! <br /> Telephone: {209) 46.647$1 <br /> APPLICATION FOR WELL'CONSTRUCTION OR PUMP PERMIT Permit No. _ � . <br /> �. <br /> TH1S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date-Issued -/��7 <br /> (Complete -In Triplicate) <br /> Application is hereby made t 'Ithe San Joaquin Local Health- District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulation's of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONQtj CENSUS TRACT <br /> Ownei Q s Name a .. 1 Phone <br /> Address >41Cy <br /> City v <br /> Contractor's Name mF . License # L a]hone Ci --76 7.Z <br /> TYPE OF WORK (Check):' NEW WELL/7 DEEPEN 1-7 RECONDITION f7 DESTRUCTION rf <br /> :P rx- 10 0 N P . ---�. PUMP INSTALLATION /7 PUMP REPAIR 1-7—Pump REPLACEMENT 17 <br /> `'f LY�cnB Other <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i <br /> Cable Tool Dia. of Well Excavation � <br /> Domestic/private -,I Drilled Dia. of Well Casing -� <br /> Domestic/public Driven Gauge. of Casing <br /> Irrigation i Gravel Pack Depth of .Grout Seal <br /> Cathodic Protection 01 Rotary Type of Grout <br /> ' Disposal i Other Other Information <br /> Geophysical w ,� ;Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ee ✓ sr ,H;P d ` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP•$E FS --§- ��� State-Vork;Done,;.7 . • - : ;::c ,,.�. ° ;: <br /> 3 <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 FII'TEEN DAYS <br /> after completion of my work on' a new well, I will furnish the San WJoaquin 'tocal..Health Distract 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 my. o ed a d belief. `TWILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG TING D A FINAL <br /> SIGNED � ITLE j� ,. <br /> DRAW LOT PLAN O RSE SIDE <br /> PRASE I FOR DE TMENT USE ONLY <br /> APPLICATION ACCEPTED Y;�� / DATE / , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BYto DATE INSPECTION BY DATE <br /> t , <br /> E H 1426 Rev. 1-74 1-74 2M <br />