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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -__ <br /> FORIOFFICE USE: 1601 E. Hazeiton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3/ 7La <br /> ' i(Complete In Triplicate) f <br /> Application is hereby made to the SarJoaquin Local Health District for a permit to construct i <br /> and/or instailwthe work herein described. This application is made in compliance with San Joaquin ,' <br /> ,County Ordinance No. 1.862 and the Rules and Regulations of the 'San Joaquin Local Health District. s <br /> JOB ADDRES1 .S/LOCATION O eV . -&C SUS TRACT <br /> Owner's Name Phone 3 <br /> - <br /> , <br /> Addressn <br /> City <br /> Contractor's Name 0. Ana <br /> ,y <br /> License Ql0 Phone g&o d <br /> i <br /> C <br /> TYPE OF WORK heck)ar_. <br /> _. { NEW`WELL /? DEEPEN '/? RECONDITION /? DESTRUCTION _� <br /> O�rI�� /LATION / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: "SEPTIC TANK SEWER LINESi 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 Ley <br /> 1 <br /> Domestic/private': Drilled � 1 <br /> Dia. of Well Casing <br /> Domestic/public.'S� _ Driven Gauge of Casing _ {. <br /> Irriga � <br /> tion; , , Gravel Pack Depth"di Grout Seal H <br /> Cathodic Protection r` ` ; s Rotary Type of, Grout <br /> ' Disposal Other_ Other'Information <br /> t_ "`Geophysical Surface Sea] Installed B "t <br /> ry r <br /> PUMP INSTALLATION: , Contractor L' <br /> Type of 'Pump i <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Donetj <br /> PUMP .REPAIR: -"` L?'"State'Work-Done _. -� - - - - , w -74 <br /> ES-TRUCT1 N OF WELL: Well Diameter , <br /> Describe Material and Procedure Approximate Depth <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 FO A GROUT INSPECTION � <br /> PRIOR TOG TING AND 9IKAL INSPECTION. ` <br /> SIGNED �. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �. <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY <br /> � , <br /> � x <br /> APPLICATION ACCEPTED BY i DATE -3-2Io <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 II ROUT INSPECTION P AL NSPECTIO <br /> INSPECTION BY DATE INSPECTION <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />