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SANSJOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued MAR 6--'"-, . <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-'Jciaquin . <br /> County,Ordinance,4cV 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/L �f�f ��r �� / CENSUS TRACT <br /> Owner's Name ������&`Q/y .p�^ Jr Phone IV g� ` <br /> Address A=' 0 .. City J 1��td. .,L/, <br /> Contractor's Name Al, W, <br /> _License Phone <br /> TYPE OF WORK (Check): " NEW WELL SDE EN -T RECONDITION DESTRUCTION <br /> PUMP INSTAL TION'/�/J—PUMP-REP.ATR. f-/--•I' RERLACEMENT.. \ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /00'_ :SEWER LINES I,6d' ' PIT PRIVY <br /> SEWAGE DISPOSAL:„_FIELD CESSPOOL/a4EE AGE PIT ----' OTHER <br /> PROPERTY LINE,.--PRIVATE DOMESTIC WELT;, PUBLIC DOMESTIC-WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial } Ajilir6*1001 Dia, of WelliExcavation /&,e. <br /> Domestic/private =Drilled Dia. of !Well�Zas-in _ <br /> - - <br /> Domestic/public s Driven Gauge..of,:Cas!: j 12 99 t <br /> Irrigation r Gravel Pack Depth of Grout�;-Seal X1.1 <br /> Cathodic Protection Rotary Type of Grout i?/:�s .P �� crrr 2r- .. <br /> Disposal Other , Others Infoimation' `"'� ; <br /> Geophysical Surface Seal Installed-Bye <br /> PUMP INSTALLATION: <br /> Contractor 1; E- <br /> Typ�,, of Pump `�� '- A.P. <br /> „`ham y �fi <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP -REPAIR: CT, state Work Done } <br /> DESTRUCTION "OF WELL: Well Diameter Approximate Depth <br /> DescriVi Material and Procedure <br /> IF <br /> I hereby agree to comply with.,:all laws and regulations of the Sa6-Joaquin Local Health District <br /> and the State_sof California pertaining to or regulating well''cons_truction. Within FIMSK thi <br /> after completion of mytwork on a new well, I will furnish the SaarJoaquin Local Health District a <br /> WELL DRILLERS REPORT of theAwell and notify them before putting the.-well in use. The 'abcve <br /> information is' true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT I$SPECTI(M <br /> PRIOR TO GROUTING AND A FINAL INS ECTION. <br /> SIGNED / TITLE 7 <br /> D LWPLAN 'ON RRVERSE SIDE) <br /> 1. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6 <br /> ADDITIONAL COMMENTS: - <br /> PHASEGRdUT i1QSP8CTI0N PHASE III FINAL INSPECT <br /> INSPECTION BY .. DATE INSPECTION BYDATE <br /> -�76 <br /> E E 1426 Rev. 1,7k :. . . � 29, . <br /> p <br />