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SAN JOAQUIN LOCAL HEALTH DISTRICT. Q <br /> FOfi.OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <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 tot,l the San Joaquin Local Health District for a permit to construct <br /> and/or install the work here i'ndeecribed. This application is made in compliance with San Joaquin' <br /> .County Ordinance No. 1862 and the Rules and Reguletione of the San Joaquin Local Health District-4 <br /> 44gL CENSUS TRACT <br /> _JOB.ADDRESS/LOCATION � / ` <br /> Phone' V <br /> Owner's Name <br /> Address `-f _ City. I <br /> License d"/9�7 <br /> I 1..1 Phone '- <br /> Nam <br /> —'Z6761 <br /> Contractor's < — <br /> j <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION R DESTRUCTION f <br /> PUMP INSTALLATION I_7 PUMP REPAIR .PUMP REPLACEMENT I—T <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 /> __ Drilled Dia. of Well Casing <br /> _ Domestic/private Gauge <br /> i Domestic/public t Driven ga of Casing <br /> Irrigation i Grave I Pack- Depth of Grout Seal <br /> Cathodic Protection !_- Rotary Type of Grout <br /> Disposal !- Other i Other Information <br /> _Geophysical--- 11p +"^ .. .`-Surf sea,"Seal,Its telled By <br /> + PUMP INSTALLATION: Contractor H.P. <br /> Type Ib f Pump ^�....✓ ne <br /> PUMP REPLACEMENT: . / / :State Work Done <br /> State Work Done <br /> PUMP tREPAIR: - /Zc7 k. .� _ . . . <br /> I. 11 - Approximate Depth <br /> j DES.TRUCTI�ON OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> d <br /> I hereby agree to comply with all':lawa and regulations of the San Joaquin Local Health District <br /> and the State of California yertaining,to or regulaping_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 wall in.use... The above <br /> information is trueto the-beetof -knowled elie£. I WILL CALL FOR AGROUf INSPECTION <br /> PRIOR TO GROUT NG-AND A FINAL INSPE N. ITLE <br /> SIGNED (D W PLOT PLAN ON ASE SIDE <br /> I FO DEPARTMENT USE ONLY <br /> I, PHASE 2 ', _ DATE -.2 <br /> APPLICATION ACCEPTED BY <br /> . ADDITIONAL COMMENTS: : - PHASH III FINAL INSPECTION <br /> PHASE II G N ECTI N INSPECTION BY �/y4�_DATH <br /> , INSPECTION By +DATE <br /> r. <br /> _ 2M <br /> 1_76 �� <br />