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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 11 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 , 7 7' <br /> (Complete In Triplicate) <br /> Application is hereby made to`Ithe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This applicatio s made in compliance with �San Joaquin { <br /> County Ordinance No. 1862 andfithe and Regulations Vthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI N � ZIA CENSUS TRACT <br /> 6 - - <br /> Owner's Name � Phonoe <br /> � f <br /> Address r Ci j <br /> Contractor's Name '+ License �D9,?3Phone0 '`''.z—_j_d_ <br /> -� 2„�y. •� �-'--_ ,J.��,`@IiYE" �''""'-bier�._ ..: -,�..'.�_ --�-- �.,;. -:ty 4., -i <br /> TYPE OFWORK {Check) : NEW WELL /� DEEPEN / / RECONDITION /-/ DESTRUCTION f_7 <br /> PUMP INSTALLATION / / PUMP REPAIR )�PUMP REPLACEMENT /� - <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANkI ," SEWER LINES 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 jam : CONSTRUCTION ,SPECIFICATIONS 0� <br /> Industrial ,t Cable Tool Dia, of Well Excavatibn <br /> Domestic/private 1 Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation. Gravel Pack Depth of Grout Seal F <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical i !' Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type o Pump H.P. <br /> PUMP REPLACEMENT: / / State" Work,Done <br /> PUMP .REPAIR:- 4 fT —St'ee Work' Da <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINALIINSPECTIOV. <br /> SIGNEDy TITLE <br /> DRAW PD` T PLAN ON REVERSE SIDE) <br /> i! FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IfTSPECTION PHASE -III/FINAL INSPECTION " <br /> INSPECTION BY DATE INSPECTION BY DATE /D-2.,4 - 74 <br /> E H 1426 Rev. 1-74 <br />