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ex -t% ,le, SAN JOAQUIN LOCAL HEALTH DISTRICT -4 <br /> FOF OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. V` <br /> Telephone : (209) 466-6781 '�,�— //3-4- <br /> � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONf D Ce S A.e1 ?x-44 .G� CENSUS TRACT <br /> Owner's Name y P Tu. I LJcca c r �� ,a ter " Phone <br /> Address �l d -� 1' .y �., f City G + <br /> Contractor's Name. License # 11 7L _Thone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION-f / DESTRUCTION /7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR /'/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE 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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS �J <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 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 /> PUMP REPLACEMENT: /,/ <br /> State Work Done <br /> PUMP /k/ State Work Done s16, t <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 FIFTEEN DAYS <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-4lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECTION ! TLE <br /> SIGNED <br /> (D 7=0 P ON RE RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE'I --� � <br /> APPLICATION ACCEPTED BY / DATE �� ��?�7 "7 <br /> ADDITIONAL COMMENTS: T' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY � DATE INSPECTION BY DATE /gar 77 <br /> n/77 _ 2M <br /> E H 1426 Rev. . 1-74 <br />