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11 SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> EOh,-ZFFICE 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 <br /> ' (Complete In Triplicate) <br /> Application is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> 5 <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 /> /0 � i A-Z <br />'JOB ADDRESS/LOCATION ^^ /QQ� y �EL CENSUS TRACT <br /> Owner's Name f/ / (f,��-� T Phone <br /> Address A0. °.�X -76 SK M. A9,e�1hr11V 61 A V6 City 5 QGW7.n/V <br /> Contractor's Name License # D�`� Phone Clqff-eY/ <br /> i <br /> TYPE OF WORK (Check) :. .NEW WELL _V, DEEPEN_/._/. -RECONDITION ./_7 -DESTRUCTION-/-7- - <br /> PUMP INSTALLATION / PUMP REPAIR, /.'./: PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ° SEWER LINES Wit. PIT PRIVY rt <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT, OTHER <br /> PROPERTY LINE-kPPRIVATE DOMESTIC WELL: PUBLICDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation. <br /> Domestic/private ; Drilled Dia. of Well'-Ga"sing <br /> Domestic/public Driven Gauge of Casing',L 6:14, 1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary _ Type-.of�Grout , MCA/77�/ <br /> Disposal Other E ��Obhei Information --^- <br /> -Geophysical "" '° ..'SurfacesSeal installed By: y� <br /> PUMP INSTALLATION: Contractor (� <br /> Type of Pump _ .S' /�_iE_/�5/��� H.P. <br /> PUMP REPLACEMENT: / / State' Work Done ' tz <br /> PUMP .REPAIR / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth \XR <br /> Describe Material and Procedure Cs <br /> I he 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 DAIS w1 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a'qj <br /> WELL DRILLERS kEPORT of the well and notify them before putting the well in use.. The above <br /> information is true to t best of my knowledge and belief. I WILL CALL! FOR A GROUT INSPECTION <br /> PRIOR TO CRO91ING 4D A&INAL INS ION. <br /> SIGNED TITLE -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) " <br /> ' FOR DEPARTMENT USE ONLY ty? <br /> PHASE I <br /> APPLICATION ACCEPTEDBY �! �. .. r DATE L� <br /> ADDITIONAL COMMENTS: i <br /> PHASE 'II GROUT INSPECTION PHASE IJ/FINAL INSPECTION <br /> INSPECTION BY DATE /-,2 =] INSPECTION BY DATE . 1 -S'-227 <br /> f <br /> E H 1426 Rev. 1-74 T 11.77. . <br />