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✓J�` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK OFFICE USE: 1601 E. Hazelton Aver. , Stockton, Calif. <br /> Telephone: (209) 466=6781 7Z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (Complete In Triplicate) <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. 18662 and <br /> �Qthe <br /> �Rule a Regulations hof the San .,Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / ��'"`" T r CENSUS TRACT <br /> Owner's Name S�E- :Z49 v /,A) Phone '` e�2 J ";`J 9 <br /> Address WCit // C <br /> k Contractor's Name- 6J IWI License 6one 4Zf G <br /> T� .-:_ -..vim <br /> f TYPE aF WORK (Check);, 'NEW <br /> NEW WELL / i7 <br /> DEEP RECONDITION 17 DESTRUCTION / jT <br /> PUMP. INSTALLATION "/% PUMP REPAIR /7 FUMP REPLACEMENT f7 <br /> Other71 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k PROPERTY LINE - PRIVATE DONESTIC-WELL- � -PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE. OF'WELL ____._.._.:_CONSTRUCTION SPECIFICAT S � <br /> Industrial. x Cable--Tool---' .`.Dia..._of Well Excavation t <br /> Domestic/private ^ Drilled Dia. of,Well Casing _ _ <br /> Domestic/public' ' t Driven Gauge of ,Casing <br /> ti Irrigation Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 4 Other Other Information <br /> Geophysical Surfa Seal Installed-Al. <br /> N 1 IN S <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump - H.P. <br /> , . _ <br /> PUMP REPLACEMENT: / State Work b e <br /> PUMP ,REPAIR: "/. / 'State +Work Donee <br /> RES+TRUCTION OF WELL: 1 . <br /> 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 "constructi.on. 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 5tPUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED;BY,I DATE <br /> ADDITIONAL COMMENTS: T <br /> PHASE -II GRQUT`I SPECTION II FINAL INSPECTION <br /> INSPECTION BY'. '; DATE INSPECTION DATEb- 4 <br /> E H 1426 _ Rev. 144' _ 14/75 2M <br />