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" " SAt�'30AQUIN LOCAL HEALTH DISTRICT { <br /> FOE OFFICE USE-: Cil' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ��-�/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> l� (Complete In Triplicate) <br /> Application is hereby made t16the 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 _ J II �3i �f��� `��� , I CENSUS TRACT <br /> Owner's Name IfIri iI <br /> Phone <br /> Address 1 City <br /> Contractor's Name /1�'!°i��'/75' !!fes License �� . Phone ' <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN / / RECONDITION /� DESTRUCTION /7 <br /> PUMP :INST�LLATION IX/- PUMP REPAIR/ / PUMP REPLACEMENT I T <br /> E Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES �j O IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT I e4 /--ETHER <br /> 1 PROPERTY LINE,/ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Ns. <br /> Industrial Cable Tool Dia. of Well Excavation ,e7 <br /> Domestic/private I Drilled Dia. of Well Casing <br /> - -- Domestic./_public ._ :� -- Driven �,. _ Gauge_ of Casing <br /> Irrigation ft Gravel Pack Depth of Grout Seal <br /> CathodicProtection Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical. � Surface Seal Installed BY: <br /> F; PUMP INSTALLATION: <br /> Type of Pump. H.P. <br /> �41 <br /> PUMP REPLACEMENT: /711 State Wbrk Done <br /> a <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well niametex 1° Approximate Depth <br /> E Desc'rib'e 'Material and Procedure <br /> I hereby agree to comply withall 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 nets well, I•will furnish the-San-Joaquin- Local Health.•.District a <br /> WELL DRILLERS..REPORT of the well and notify them before putting the .well in use. The above <br /> information isLtrue'-to the--bes-t of my.knowledge and belief:., I WILL CALL FOR A GROUT INSPECTION <br /> t PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED -LE <br /> (D W pL ON RE EkSE SIDE is <br /> FOR D ARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> { INSPECTION BY DATE INSPECTION BY AV DATE <br /> E H 1426 Rev. 1-74 - <br />