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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF *OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. t <br /> 4 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. jQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Hereby made to'Ithe San Joaquin Local Health District for a permit to construct j <br /> and/or .install they 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. ,i <br /> JOB ADDRESS/LOCATION 'f .11 a-- Z CENSUS. TRACT <br />.Owner's Name.. <br /> Phone <br /> Address w al/1 ► �'�cr City. �t.oi rd' <br /> Contractor Name / License # l c3-7A Phone -;X—76 7 <br /> TYPE OF WORK (Check) : NEW WELL -/7 DEEPEN -/-7 RECONDITION %7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / PUMP REPLACEMENT 17 <br /> Other <br /> Ll I <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> ')e Domestic/private ;i Drilled Dia. of Well Casing i <br /> Domestic/public =IDriven -. Gauge of Casing l <br /> Irrigation +I Gravel Pack Depth of Grout Seal <br /> Cathodic Protec.t_ion '. Rotary Type of Grout <br /> Disposal A Other Other Information ' ' � <br /> Geophysical Surface Seal Installed 'B i <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> fa Type of Pump $.P# , <br /> PUMP REPLACEMENT: /7 State Worlc-Done- <br /> PUMP ,REPAIR: ICI State Work Done is /r�4,!ter <br /> DES-TRUCTION 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 an 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. m. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ; PRIOR TO GROUTING AND A FINAL INSPEbjIO . <br /> r. SIGNED TITLEirc^./ <br /> DP49PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> APPLICATION ACCEPTED BY DATE IS 76 <br /> ADDITIONAL COMMENTS: <br /> PHASE II.GROUT INSPECTION PHAS FIN INSPECTION <br /> 7FTSPECTiON BY DATE INSPECTION BY DATE �� <br /> E R IA76 Roxy- 1-7G 4/15__ 2M <br />