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SAN JOAQUIN LOCAL HEALTH DISTRICT 0t�j <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71-67-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� <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 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 40 Ai 4k/.C, CENSUS TRACT <br /> Owner's Name PhoneJ _ j <br /> Address �_ City 42st'''i¢4�✓ - <br /> Contractor's Name _ ,� 1�s c 1 ✓ _ _ License #a;7d t1 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION jK PUMP REPAIR / / PUMP REPLACEMENT <br /> Other — h <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _- PIT PRIVYO <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ------PROPERTY LITE--t'R'tVA"TE-D0MESTiC WE-I hn---PUBLIC DOMESTIC WELL p <br /> INTENDED.: USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia, of Well Excavation 6\; <br /> Domestic/private,xti" Drilled. Dia. of Well Casing J <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 => 1 •. k Other Information 'r <br /> Geophysical � �� � Surface Seal Installed' By : <br /> PUMP INSTALLATION: Confr-actor <br /> t^.., Type of Pump - - + -- H.P. <br /> i <br /> PUMP REPLACEMENT: / s/. "StatexWo�rk.tD r►e <br /> �- � <br /> PUMP .REPAI / / StaE6 Work Done f <br /> 7 l.J L /. P oi� ,C� <br /> DESTRUCTION OF WELL: Well, Diameter �� � G `G� � Approximate Depth F6 <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�we�ll 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will. �urni ii ,the San-Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell 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 GRO ING AND A INA INSPECTION. <br /> SIGNED , % ,TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID } <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE '�'a�� <br /> APPLICATION ACCEPTED BY _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I 1/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/Z j -- <br /> 6, %7 2M ?K <br />