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= z" OSAN JOAQUIN LOCAL HEALTH DISTRICT $ <br /> F69 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 3_ �24F <br /> (Complete In Triplicate) 2V-7~-/4,0'"l3 <br /> Application is hereby made 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._1862a,.and..the Rules and Regulations of the San Joaquin Local Health District. <br /> r�0re7 S--.MG44lrJ <br /> JOB ADDRESSIICATION !21 <br /> . ' - cENsus TRACT <br /> t <br /> 'Owner°s Name Phone <br /> `Address a City ZSf&A"441 <br /> Contractor's Name -7;,o A) .! - License #027Phone <br /> TYPE OF WORK (Check)-:—NEW WELL l_7 DEEPEN '/? RECONDITION /� DESTRUCTION f7 r <br /> PUMP INSTALLATION / PUMP REPAIR � PUMP REPLACEMENT /? <br /> Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER .LINES PIT PRIVY _ . ': <br /> < , SEWAGE DISPOSAL FIELD 1 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL I 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 <br /> Irrigation Gravel Pack E. Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br />{ Geophysical Surface Sealnstalled'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP`.REPAIRi l'�"'� -State Work Done �yl�/gUAYo��-� t/adf� &V <br /> ES;TRUCTION OF WELL: Well Diameter J Approximate Depth <br /> Describe Material and Procedures <br /> I herebp agree to comply with all laws and regulations of the San Joaquin Local Health District z <br /> and the State of California pertaining to or regulat.ing 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 GROUT INSPECTION <br /> PRIOR TO GROU NG ANDA ZINA.L INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> M DE T NT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED DATE <br /> „ ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P#Kg I I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTf S <br /> t E H 1426 Rev. 1-74 1-74 2M <br />