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i SAN JOAQUIN LOCAL HEALTH. DISTRICT <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. /1/7 <br /> Pl -O­ u� 6 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby ihade 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 : d /Regulations of the San Joaqui Local Health District. <br /> JOB ADDRESS LOCATION NSUS TRACT <br /> 02 <br /> Owner's Name 7 �'�/'� Phone <br /> de�JIAIP <br /> Address <br /> k Contractor's Name x' 'Pei LicensGoO/&-3:)--3Phonfig'g4g96'� � <br /> 1 <br /> ..��'."�`.-�.�.���.��-. - ._»i �..a+9wq .•�-.ti<<!tsr.-x'^���Y ter.- <br /> TYPE OF WORK (Check) : :NEW WELL / / DEEPEN / / RECONDITION / .DESTRUCTION <br /> ':..PUMP INSTALLATION/ / PUMP REPAIR IM PUMP REPLACEMENT /7 <br /> Other / / <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 9 I! TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia. of Well Excavation <br /> Domestic/privatell Drilled_ ;. Dia. of Well Casing . <br /> Domestic/public II Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> j Disposal j Other Other Information <br /> EGeophysical -_ .s; I Surface Seal Installed By: <br /> € PUMP INSTALLATION: !'Contractor <br /> f ilType of ,Pump H.P. <br /> PUMP REPLACEMENT:/ />: .State Work Done <br /> PUMP .REPAIR: zu- <br /> I� State Work Don . _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 'Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws. and regulations of the San.J,oaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of myjwork'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 thewell 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 GROUTING AND A FINAL INSPECTION. <br /> r SIGNED TITLE ✓. ��.; T <br /> D W:P1 T' PLAN 'ONrrny REVERSE SIDE) �� � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> h APPLICATION ACCEPTED BY A DATE <br /> ADDITIONAL COMMENTS: it <br /> PHASE II GROUT INSPECTION PHASE 4 I/FINAL INSPECTION <br /> E INSPECTION BY i, DATE INSPECTION BY DATE '7 <br /> E H 1426 Rev. 1-7LI4 3/76 2M <br /> If 1.001.- <br />