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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .nd/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .0B ADDRESS/LOCATION � 'j �n V CENSUS TRACT — <br /> ^aner's Name �n 6 S'T� LPhone <br /> Address _LjP ( , ��.iS— �z',q _ City star <br /> — <br /> mtractor's NameIgIgu_ ��A-_7 License #&_41p,,< -T <br /> tPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> .. PUMP INSTALLATION /bf PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK 1692L, SEWE /071 1 PIT PRIVY <br /> ,R�L7'IYNES <br /> SEWAGE DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE/S PRIVATE DOMESTIC WELL .7aj 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 L <br /> Domestic/public Driven Gauge of Casing \ <br /> Irrigation Gravel Pack Depth of Grout Seal 4 <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> IMP INSTALLATION: Contractor 11,v, e t X�k g,014 y [f✓ f fi <br /> Type of Pump 'A 1 r ^ H.P. oe rC <br /> "JMP REPLACEMENT: / / State Work Done <br /> ITMP .REPAIR: / / State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ,,,id 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 /> "sLL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> iformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> MIOR TO GROUTIN D A FINAL INSPECTION. " <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) a. arch <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> p 'PLICATION ACCEPTED BY � � DATE <br /> lODITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 7SPECTION BY DATE INSPECTION BY DATE <br /> h/77 ou <br />