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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone : (209) 466-6781 7-7 3y , <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 /> 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 /> 6 y ;_.7-ma ,� oaf— 0-50- 03 <br /> JOB ADDRESS/LOCATION I��; 7,jIQ ?N T��!_,.���..���C. CENSUS TRACE <br /> Owner's Name TJ 'sG/Y Phone <br /> Address !• �. ax 214P ; - City �'T�GIK7clyl <br /> Contractor's Name License �� 612- <br /> Phone <br /> a <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / f 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 <br /> Industrial ^ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 12 j <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 /> J <br /> Geophysical Surface Seal Installed By: _ <br /> .fi I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> i <br /> PUMP REPLACEMENT: / / 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 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 an 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 U IN D, 1NAju INSPECTION. / <br /> I. SIGNED TITLE a ry <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL COMMENTS: <br /> I PHASE II GROUT INSPECTION II/FI INSPECTION <br /> INSPECTION BY DATE IN I DATE <br /> 6/77 _ 2M <br /> E H 1426 Rev. - 1-74 <br />