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SAN JOAQUIN LOCAL HEALTHDISTRICT <br /> FOL �IF " CE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46676781 <br /> 7ABPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f ± THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t: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 and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION 0*41441 . CENSUS TRACT <br /> Owner's Name 7 n v 4-'- �l �?I'1etPhone <br /> Address r f5 � t 4,0A. city _ !! fay' Ck�( <br /> .a License'# /f,3# hone , -o-- �7Z <br /> Contractor's Name �-. / <br /> Y t <br /> TYPE OF WORK (Check): NEW WEED /-7 , DEEPEN /_RECONDITION DESTRUCTION f-7 <br /> r <br /> PUMPINSTALLATION ,/�C/ PUMP.REPAIR'<7 PUMP REPLACEMENT ,% <br /> 'Other .L:7- <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK c SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTBRR <br /> ' PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i� Cable.Tool Dia. of Well. Excavation <br /> t - <br /> Domestic/private Drilled Dia. of Well Casing <br /> r Domestic/public i Driven'"' Gauge of Casing <br /> 'Irrigation i Gravel Pack Depth of Grout Seal <br /> Y Cathodic Protection Rotary Type of Grout <br /> _ Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor < <br /> Type of Pump ', H.P. <br /> F <br /> PUMP REPLACEMENT: / / lS.tate ,Work Done _ <br /> PUMP .REPAIR: /�C/ State Work Done yl� 06�rs, fG� ,c�OJf� <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. FIFTERN DAYS.. <br /> after completion of my work on anew 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 isutrue to the-best of my knowledge and elief. I WILL CALL FOR A GROUT Il'SPaCTI(3TT.: <br /> PRIOR TO _ T NG .AND A FINAL INSPECTIO <br /> SIGNED <br /> _ LE, <br /> F W: �WON REV SE SIDE :: <br /> w <br /> ARTMENT USE ONLY ` <br /> PHASE I \\ a <br /> APPLICATION ACCEPT" �7, DATE <br /> ADDITIONAL COMMENTS: <br /> iPHASE II GROUTINSPECTiON PHASE III FINAL' INSPECTION <br /> IN BY DATE INSPECTION BY DATE V47-7 <br /> 7 <br /> �' E 1426 $eV• �-/ ♦ m... -T..... ;. .l. .. -4 _ - ♦ - F. 31 i. <br />