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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT.,OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�6.5 /}� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct <br /> rind/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 , CENSUS TRACT <br /> Owner's Name Phone <br /> Address ,�' C�0 yS l � � -✓" �-rt City <br /> Contractor's Na License # Zy��hone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/_7 RECONDITION / DESTRUCTION j <br /> PUMP INSTALLATION /—/ PUMP REPAIR -&7—PUMP REPLACEMENT f <br /> Other El <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 (� s <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 "�"""�- <br /> Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor *�� a 9 ' <br /> Type of Pump ! { <br /> H.P. .,,c] . <br /> PUMP REPLACEMENT: - / / State Work Done ; <br /> PW ,.REPAIR: State Work Done <br /> DESTRUCTION 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.knowl die aid belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG U ING AND A FINAL IN . <br /> SIGNED Qy/� TLE <br /> _YCD_aW PLOT 13KA-_N ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />_PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA INSPECTION <br /> INSPECTION By _ 04 DATE INSPECTION BY/INN DATE -y <br /> E H 1426 Rev. 1-74 4/75 - <br />