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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOR OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> IM <br /> Telephone : (209) 466-6781 <br /> !� APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit <br /> �M <br /> .e THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued <br /> ro� (Complete In Triplicate) <br /> Application is hereby made I 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 /> CGnty Ordinance No. 1862 and the Rules and Regulations .of the. San Joaquin Local Health District. <br /> JO 11� <br /> B ADDRESS/LOCATION 3 d3 JSI fit, fzj CENSUS TRACT. <br /> OF <br /> Owner's Name d ,/ EmsZ/ Phone <br /> / <br /> Address / �it� y��. CitY a w_ <br /> Contractor's tractor's Name �.y License # /I ]Zrlone Y �� <br /> PE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> TY' _ <br /> PUMP �INSTALLATION / / PUMP REPAIR bC/ PUMP REPLACEMENT <br /> Other <br /> DILSTANCE 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 /> INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �. Industrial ! Cable Tool Dia. of Well Excavation C.\ <br /> ;I Domestic/private A Drilled Dia. of Well Casing O <br /> EM X Domestic/public 1 Driven Gauge of Casing C <br /> !� Irrigation Gravel Pack Depth of Grout Seal <br /> �. Cathodic Protection Rotary Type of Grout N, <br /> .11. Disposal `Other Other Information <br /> iM Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: 'Contractor 9-l/ <br /> Type of Pump H.P. <br /> F PUMP REPLACEMENT: / / Stateb-Work'Done: E \ <br /> PUMP .REPAIR: /?C/ State Work Done <br /> DES-TRUCTION 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 Distract <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> atter completion of my work on arnew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in use.... The above <br /> information is true to the best of; Y kno ledg and belief. I WILL CALL FOR A GROUT INSPECTIONRIOR TO GROUTIN AND A FINAL INSPECTI <br /> SIGNED C ITLEryJ' — <br /> { P OT FLAN 0 VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `��-7� <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT; INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /',Q __- DATE <br /> E� <br /> 077 <br /> -_ 2M <br /> --- <br />