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PJ <br /> 4 SAN JOAQUIN LOCAL HEALTH DISTRIC -- <br /> - <br /> FQ „0 'FICE USE: 1601 E. Hazelton Ave. , Stockton, Cali f- 7� I7$ <br /> !' Telephone: (209) 466-6781. `—'�— <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �v Z <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 madein compliance -.with San Joaquin <br /> County Ordinance. No. 1$62 and the Rules' and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .. ; CENSUS TRACT <br /> Owner's Name ./[ Phone WZ�a -- D''7 F-2 , <br /> Address s �-c \ (� City <br /> Contractor' <br />� 's NameA�K_e License �����v.� Phone <br />� t <br /> M <br /> C i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> -- — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, PIT PRIVY <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC-WETrL PUBLIC_ DOMESTIC WELLT <br /> INTENDED USE (TYPE OF WELL .',: CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia—. of Well Casing � (� <br /> Domestic/public Driven Gauge OfCasing <br /> w� "Ir i tion, Graved Pack Depth of Grout Seal. � <br /> -Ca•th�die- Rrotecton-�= —Rotary--- --Type-of-Grout <br /> Disposal Other Other Information <br /> GeopYysical Surface Seal Installed By: <br /> PUMP` INSTALLATION: Contractor <br /> � Type of Pump _ H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DE ,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> P_.�o 0, eW Describe Material and Procedure <br /> P 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'constructi.on. Within FIFTEEN DAYS <br /> 4 after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 GROUTING AN. A FINAL INSPECTION. <br /> SIGNED , TITLE <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED BY DATE �0_0 -1� <br /> ADDITIONAL' COMMENTS: G <br /> PHASE I GR UT TNSPECTION HA III/FINAL INSPECTIO <br /> t INSPECTION BY F DATE INSPECTION BY DATE <br /> ' t �� �T — r----^—� <br /> 07 2M <br /> E H 14 , Rev. • 1-74 <br /> _ <br /> 26 <br />