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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.?U_a 994 <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��/�/� /(� �/ � fC!-_' ,10ENSUS TRACT <br /> Owner's Name it / -3� � �y�� <br /> Phone �� <br /> Address \n / <br /> City <br /> Contractor's Name �i�G 1z i .� - License # qrY U r <br /> ,C,. .�J� Phone +����,-'�. fr' <br /> TYPE OF WORK (Check) : NEW WELL L0, DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLAC /7 <br /> Other /7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT //6 / 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 zlO <br /> TDomestic/private Drilled Dia. of Well Casing <br /> 2L 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 /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump )ri /i. H.P. " <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: /7 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true the;best of my Otowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINL. D A .rlNAL I2JSPE ON. <br /> SIGNED 'i <br /> aL _ (DRAW PLOT PLAN ON REVERSE SIDE) l: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE_ �p / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / /s 7 J INSPECTION BY ✓_ DATE / <br /> E H 1426 Rev. 1-74 1-74 2M <br />