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Dg SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh'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 ,,-7--2 <br /> (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 1862 and the Rules and Regulations of the Soman Joaquin Local Health District <br /> f pC7 Fi�J, 'f l,Ga#l�(G✓!� f �,u .S/7N;/ <br /> JOB ADDRESS/LOCATION ASI- "A CENSUS TRACT <br /> Owner's Name y6 Phone - 4ZSr` 1 <br /> Address <br /> LT D N City 5 Z�C; k a326/ . <br /> Contractor's Name '/7Pv G License 200`79y Phone <br /> A <br /> TYPE OF WORK (Check) : NEW WELL _0 DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> O <br /> Other / / 0.;,. <br /> DISTANCE TO NEAREST:.. SEPTIC TANK zaQ/ SEWER LINES _42jI;p PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> x Domestic/private Drilled,_ Dia. of Well Casing <br /> ^7X Domestic/public Driven Gauge bf Casing p G , <br /> Irrigation Gravel Pack Depth of Grout Seal 3 <br /> Cathodic Protection X _ Rotary Type of Grout jAgsl TE <br /> Disposal Other Other Information <br /> Geophysical /�� /6�rd j � Surface Seal ns a ed B • c_ <br /> Ate/ � " G' 33'-Go •�. <br /> PUMP INSTALLATION: Contractor U 3 <br /> Type of Pump C-61V H.P. 1 f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: / / State Work Done r <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 District <br /> and the State of California pertaining to or regulating well -'construc 4on. Within FIFTEEN DAIS <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 GRO&TING ANDA FINAL I PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P SE I GROUT INSPECTION PHASIYIIYAAL MPXCT Oky <br /> INSPECTION BY DATE 2 8 INSPECTION BY A <br /> E H 1426 Rev. 1-74 <br />