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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP E IT ermit No.gh,,gig <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEI Issued ��b-& <br /> (Complete In Triplicate) <br /> Application is re y•` e to the San Joaquin Local Health District for a permit to construct <br /> and/or install the worklherein 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 /> 1 I' <br /> JOB ADDRESS/LOCATION L I(/ 7 C1, CENSUS TRACT f Ot?'-17Gry.6 <br /> Owner's Name /� Phone <br /> Address A 0. <br /> City /'71?. K2�c_.Cc <br /> Contractor's Name �W ar, -Po- License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DE <br /> , IEPEN /% RECONDITION / / DESTRUCTION /_7PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY IN <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 /> 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 . & y j <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP �REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply', wi.th 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 belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR T OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r- - DATE <br /> ADDITIONAL COMMENTS: <br /> P IL GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY INY DATE <br /> E H 1426 Rev. 1-74 1IZ7 2M <br />