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FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLUATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 , <br /> SC m i TRX PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-4a"]� <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 Joaquin <br />,ounty Ordinance No. l an gegulations of the San Joaquin Local Health District. <br /> OB ADDRE SAO `,� m D-r `,I CENSUS TRACT <br /> Owner's Name �Gy Q 7.0 r d Phone <br />.ddress .S s� J b �a �y o City �p�GIG7�j� <br />;ontractor's Name �j License # �j7iA-Phone L - W74 <br />'YPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR Ig PUMP REPLACEMENT <br /> Other <br />)ISTANCE 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 (A <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing („ <br /> Irrigation Gravel Pack Depth of Grout Seal r! <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information rn <br /> Geophysical Surface Seal Installed By: Q <br />'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. 2�( <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP .REPAIR: / State Work Done Z&Ly -� <br /> LESTRUCTION 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 Distric <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />.fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />°ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.nformation is true to the best of my ka ir'ledge be ief. I WILL CALL FOR A GROUT INSPECTION <br /> IRIOR TO GRO I4 AND A FINAL I <br /> iIGNEDTLE �►��(' � <br /> (D P T P ON RSE SIDE <br /> DEPARTMENT USE ONLY <br />'RASE -I <br />.PPLICATION ACCEPTED BY LDATE <br />.DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE III/FINAL INSPECTION <br />.NSPECTION BY DATE INSPECTION BY DATE ' -7 7 <br /> E H 1426 Rev. . 1-74 <br /> b/77 _ 2M <br />