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—C40 AlVSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx:� F CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> q:. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-- d--7-- <br /> (Complete In Triplicate) <br /> Appliceti6i is hereby made to the Son 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 /> ,2 CO Atlkf <br /> JOB ADDRESS/LOCATION /1�0 „ LeJw v� e res+ CENSUS. TRACT <br /> Owner's Name �� c 4 %�,�,1a Phone <br /> Address L. .n dft•.-4MAW �1city - <br /> Contractor's <br /> ity -Contractor's Name ,,,)�(� 4 �f{j License # 'Phone _3�g 2�-Z/-,7� <br /> TYPE OF WORK (Check): NEW WELL"/-7 ' DEEPEN /? RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION /?C/ PUMP REPAIR 1_7 PUMP REPLACEMENT /7 <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <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 /> )0 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 By: <br /> PUMP INSTALLATION. Contractoro <br /> Type of PumpH.P. ' <br /> PUMP REPLACEMENT: . / / State Work Done 1 <br /> PUMP . + / / State Work Done <br /> DES-TRUCTION 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 Distri <br /> and the State of California pertaining to or regulating well''construction. Within FIFTEEN DA <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a t <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 my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT N. } <br /> SIGNED �` !Zej:. - ITLE <br /> (D W LOT PLAN ON RE RSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 'zZi L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASK III INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 V75 M <br />