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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> yo-ReOFFICE USE: YYY 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> A - I (Complete In Triplicate) ��— oe o -� <br /> Application 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> fiZ3 z3. 4 - `p"� D i a U TH Ili i�rca-- <br /> � � <br /> JOB ADDRESS/LOCATION =f 1-��' 7�rf �.n1 �� r7 �,.Sr . '� JS TRACT <br /> Owner's Name � GAJ n�J f Phone 1e <br /> Address -lamJ7� �` City �hTr��✓� <br /> f <br /> Contractor's Name ���`7`-�3 /"�'�/�-� License �G�-3� Phon4ZIe�G r <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ w <br /> PUMP INSTALLATION /-7 PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> a <br /> 4 ` <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES FIT 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 <br /> Domestic/private Drilled Dia.- of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection } Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type 6f Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> State Work Done•- - / 777 <br /> ES-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 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ! TITLEyam, <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> B H 1426 Rev. 1-74 1-74 2M <br />