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WIN <br /> ' 1 SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> FOHrOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif.. <br /> Telephone: (209) 466-67-81 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s�5-/� <br /> THIS PERMIT EXPIRES 1 YEAR-.PROM DATE ISSUED Date Issued /--24-/-5-- <br /> (Complete <br /> --Z4-JS(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 /> JOB ADDRESS/LOCATION- A/ CENSUS TRACT <br /> Owner's Name Phone <br /> Address- City <br /> Contractor's Name . T7-,qA/i S t A 0 s �✓/N � License Phone 1 <br /> TYPE OF WORK (Check.): NEW WELL L7 DEEPEN/7 RECONDITION /_� DESTRUCTION LT <br /> PUMP INSTALLATION / / PUMP REPAIRS/>7 T PUMP RERL`'CEMENT <br /> Other 1 IT ------g4c _,__ ..!N iv_<,_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL 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 I <br /> Domestic/private Drilled Dia. of Well Casing <br /> . � Domestic/public ! Driven- " ' Gauge of Casing t f <br /> Irrigation ' ' , Gravel Pack Depth of Grout Seal l <br /> Cathodic Protection Ii Rotary Type of Grout <br /> Disposal 1 Other Other Information ! <br /> Geophysical t Surface Seal Installed By: <br /> PUMP INSTALLATION: Contr ctor , <br /> Type. f .Pump A.P. �C <br /> PUMP REPLACEMENT: j S tate ;Work Done $ <br /> `► N- <br /> PUMP '.REPAIR: State 'Work Done cy <br /> II+ ZESTRUCTION OF WELL: We11 Diameter Approximate Depth i <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..welf in .use. -The above <br /> information is true to the best of my,know7,A/ <br /> dge and belief I WILL CALL FOR A ROUT INSPECTION <br /> PRIOR TO ROUTING AND A FINAL INSPE ON. f TITLE <br /> t t F DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C:;/��i%?��_ DATE <br /> f ADDITIONAL COMMENTS: <br /> f PHASE II GROUT INSPECTION PRASE-,III/FINAL INSPECTION f 3 — <br /> INSPECTION BY DATE INSPECTION BY '.%�'��' DATE - <br /> E H 1426 Rev. 1-74 1-74 2M <br />