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SAN JOAQUIN LOCAL HEALTH DISTRICT _k <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f � 7�-/3 9lti <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED ' Date Issued 4-lq 3 �~ <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 <br /> the San Joaquin Local Health District. <br /> i <br /> :YOB ADDRESS/LOCATION CENSUS TRACT <br /> E Owner's Name U Phone <br /> Address <br /> City <br /> Contractor's Name ' <br /> tidid V cense �t 03 Phone <br /> TYPE OF WORK (Check): NEW WELL/ EEPEN / CONDITION /� DESTRUCTION _ <br /> PUMP INSTALLATION / /?PUMP REPAIR PUMP REPLACEMENT . <br /> O Cher j % <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> -SEWER LES .---_ PIT PRIVY:._------ <br /> SEWAGE DISPOSAL FIELD SSPOOL/SEEPAGE PIT/ a ' <br /> . <br /> PROPERTY LINE=PRIVATE DOMESTIC WELL _�-- PUBLIC DOMESTICWELL- --�- <br /> - h' 1 <br /> INTENDED USE TYPE OF WELL CONSTR <br /> IndustUCTION SPECIFICATIONS <br /> rial <br /> Cable Tool Dia. of Well Excavation <br /> mastic/private I Drilled Dia. of Well Casing — I <br /> 1 Domestic./public Driven Gauge of Casing <br /> Irrigation Gravel Pack . � f Depth of Grout Sal <br /> Cathodic Protection i .11Rot-ary Type of Grout' ' <br /> � . Disposal ! Other Other Information <br /> Geophysical Surface Sea! Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of, Pump r - . <br /> 1 H;P. <br /> 1 ;u <br /> / + <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP!REPAIR:, ., ..,,,4 / ;State=:Work-Done <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> , Describe Mater al and/Procedure <br /> ,u tol I - <br /> I hereby agree to comply withlall laws and regulations,,of fhe S n Joaq n,Local Health Dist ict <br /> and the State of California per 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 thel-well and notify them before Putting`the..well in.use.. The above <br /> inf tion is true to the. my.kiiowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTING AND A N E' IQ- <br /> SIG <br /> TITLE Y—r�at qr1` <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHA FOR DEPARTMENT USE -ONLY € <br /> / € <br /> APPLICATION ACCEPTED BY, <br /> ADDITIONAL COMMENTS: DATE <br /> i PHA§ II ROU INSPECT NV. <br /> INSPECTION BY D .E -;. ry PHA I FIN INSP�CTI : <br /> INSPECTION BY DATE <br /> . E H 1426 Rev. <br /> n:/Z JOA. 7-7/. nt <br />