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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP- 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 l YEAR FROM DATE ISSUED Date Issued - <br /> (Complete In Triplicate) <br /> Application is hereby made tothe 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 and Regulations of the San Joaquin Local Health District. <br /> �l- �t <br /> JOB ADDRESS/LOCATION J�� d 6 zb CENSUS TRACT <br /> Owner's Name -jr �(��]1�.5 Phone <br /> Address 5"? fST t On City �] <br /> Contractor's Name C.L-a Mir +.r � u] lyr License # 660Z - Phone�6�f� <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN%/ RECONDITION / / DESTRUCTION /_7 ' <br /> PUMP'INSTALL.&TIONI / /ZP-,U REPAIR / / PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTM,TANK +r 5SEWER- LINES j+ PIT PRIVY 3 <br /> SEWAGE DISPOSAL FIELD 5 ' CESSPOOL/sSEEPA'GE PIT OTHER <br /> PROPERTY LINE_= PRIVATE DOMESTIC WELL .'- '`PUBLIC DOMESTIC WELL <br /> IN NDED USE TYPE OFEWELL # '� � CONSTRUCTION SPECIFICATIONS <br /> ndustrial I Cable .Tool I Dia." of)Well Excavation <br /> Domestic/private Drilled" , 4 � _... ._ <br /> /P 1 Drilled ; Dia. of-W611'Casin9 <br /> Domestic/public 7Driv n °, Qauge;oft Casing /b <br /> Irri ation <br /> g I avel Pack ; Depth of Grout Seal Sa <br /> i.r. <br /> Cathodic Protection Rotary � �ii ype of Grout's H IST <br /> Disposal t Other Other Information X"t <br /> Geophysical Surface Seal Installed? B : L <br /> PUMP INSTALLATION: Contractor r <br /> Type of- Pump H.P. <br /> � s.l <br /> PUMP REPLACEMENT: State Work Done i <br /> PUMP ,.REPAIR: , <br /> � / / State Work Done <br />)ES•TRUGTION OF WELL: Wel1,,Di'ameter Approximate Depth <br /> Describe Material and Procedure <br /> E 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 onia 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 />'RIOR TO G TING D A FINAL-IN ECT ION. nn <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON-REVERSE SIDE) j <br /> FOR DEPARTMENT USE, ONLY <br /> PHASE I <br />�PPLICATION ACCEPTED BY ._ DATE "0 !� <br /> ADDITIONAL COMMENTS: Ak <br /> kH&KgI CR_MT INSPECTION P I• FINAL INSPECTION <br /> INSPECTION BY DATE tj2A INSPECTION BY DATE <br /> E H 1426 Rev. 1.-74 117.7 2M M <br />