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Co P A, SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z(z/o 7Scp� <br /> 1 <br /> THIS PERMIT MIRES 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ t7 pSd 4 �,e/7/-- CENSUS TRACT <br /> Owner's Name - Phone <br /> Address -F /Ari' City �rdm44 !" <br /> Contractor's Name License # hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /'7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other / / <br /> DISTANCE 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 <br /> _ Domestic/private Drilled Dia, of Well Casing <br /> 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 Bk <br /> 1 � <br /> PUMP INSTALLATION: Contractor Cz , <br /> On <br /> Type of Pump �-,{ H.P. ACz,- <br /> PUMP REPLACEMENT: />% .State Work Done <br /> PUMP .REPAIR: / / State Work Dane <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of - no dg an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND A FINAL/4-NSIO <br /> SIGNED <br /> RA -PLOT Pt <br /> AN 'ON SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -Z LL- -ZL <br /> E H 1426 Rev. 1-74 . <br /> 3/76 2M <br />