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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE�USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ��J3/� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I 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 /> 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 Re ulat'o s of the San Joaquin Local Health District. <br /> 1.2(04i \fnto A«4N �'t q <br /> JOB ADDRESS/LOCATION K CENSUS TRACT <br /> Owner's Name A Ar Q e j, Phone W7c2147 <br /> Address �' V.4)V ALL Al City �LSC�gaL-/ <br /> Contractor's Name ,� � _ ,,� License #J d d Phone i2,j X-.224 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION-/ / DESTRUCTION <br /> PUMP INSTALLATION _PUMP REPAIR /�/ PUMP REPLACEMENT <br /> Other / OAD Wet 13 7'E 0,,JL'3r Pe��[ y 041;;7ej. <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing , � <br /> Domestic/public Driven Gauge of Casing S <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary E Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal-_Installed By: <br /> PUMP INSTALLATION: Contractor 71W � <br /> Type of Pump KT'c. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .. T- ! Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all-laws and regulations of the San Joaquin Local. Health Distract <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 /> PRIOR TO GROUTING AND FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> IR <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 /I W <br /> ADDITIONAL COMMENTS: <br /> PHASE II-GROUT-INSPECTION PHA E /FIN INSPECTION �j <br /> INSPECTION BY DATE �� ---- INSPECTION BY ATE 7�J <br /> _ <br /> n�77 . <br /> E x 1426 Rev..�4- __ - . <br />