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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FOROFF-`.iCE USE: 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 Issuedy -2j_-1S <br />(Complete In Triplicate) 2z -k- 13�o 2P , <br />Application is hereby made to the San Joaquin Local Health District fo:r 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. -� u! t CENSUS TRACT 1 <br />"� • <br />Owner's Name /& Eel _�� _ Phone- 5W- 1196 ' <br />' I <br />Address 7 71 Cn • /,;-70_ city.. 2e- t <br />Contractor's Name�I i s s <br />- License # , 90 I3 Phone <br />s .3 <br />TYPE OF WORK (Check): NEW WELL IjY DEEPEN /% RECONDITION /% DESTRUCTION f% <br />PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT *f% <br />Other /-7 , <br />DISTANCE TO NEAREST: SEPTIC TANK /po SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI'S 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 Excaval-ion " <br />Domestic/private t Drilled Dia. of Well Casing <br />_ Domestic/public I Driven Gauge of Casing 1�A <br />Irrigation E Gravel Pack Depth of Grout Seal +, i <br />Cathodic Protection i L,Rotary.,,_._ _ ,-Type_of ..Grout <br />Disposal Other' Other Information <br />Geophysical j F "�,� Surface Seal Installed By: �t <br />PUMP'INSTALLATION: <br />PUMP REPLACEMENT <br />PUMP '.REPAIR: <br />DESTRUCTION OF WELL: <br />r <br />Contractor <br />Type of Pump H.P. <br />/% State Work Done <br />/ ! 1 ' <br />_ State Work ,Done <br />wWell Diameteri ro . Approximate;Depth <br />Describe Material and Procedur_e0s I1 <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"construct:.on. 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 use.....The above <br />information is true to the best of my..knowledge and belief. I WILL CAIL FOR A'GROUT INSPECTION <br />PRIOR TO OUTING INAL. INFEECTi <br />SIGNEDTITLE �C <br />t (D PLOT LAN ON REVERSE SIDE <br />OR .DEPARTMENT USE ONLY <br />PHASE I �---- <br />1CATION ACCEPTED BY DATE - 73 <br />t,--iTIONAL COMMENTS: t - <br />PHASE If GROUT INSPECTION PHASE II]: FINAL INSPECTION <br />INSPECTION BY DATE -r2 - $'� INSPECTION BY �/�,� DATE 6 -11-2ZP <br />E.H 1426 Rev. 1-74 ?x/75 2M <br />