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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. A '7z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> F Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> M 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 Q IKI;'f Z i ,ua Z2el9 i9 CENSUS TRACT <br /> Owner's Name J/'/� (� /� _ Phone <br /> Address aLq Z City <br /> i Contractor's Name r"221&4 License #o9l?96/d Phone <br /> h ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_7 DESTRUCTION: /? <br /> PUMP INSTALLATION/ / PUMP REPAIR 07PUMP REPLACEMENT /? <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 /> I INTENDED -USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial `, Cable Tool Dia. of Well Excavation <br /> i Domestic/private , Drilled Dia. of Well Casing <br /> ` Domestic/public Driven; Gauge of Casing i q, <br /> Irrigation Gravel Pack Depth of Grout Seal q\ <br /> Cathodic Protection -, Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed-BY: <br /> PUMP INSTALLATION: Contractor <br /> .__T.ype._of-Pump.-Pump_----- -- -- - - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done ._ <br /> PUMP .REPAIR: State Work Done AnD <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 thewell and notify them before putting the -well in use. The above <br /> information is true to the 'best-af my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO ROUTING gD & FINAL INSPECTION. <br /> E SIGNED TITLE <br /> DRAW PLOT PLAN 'ON REVERSE SIDE ,'' �' ' <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEjjTI/FTNAV INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /� DATE p <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />