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t <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave ., Stockton, Calif, <br /> Telephone; . <br /> p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedy <br /> (Complete In Triplicate) <br /> AApplication 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 Joa <br /> P qu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San.-Joaquin Local Health District <br /> I JOB ADDRESS/LOCATION 16 70 <br /> S ' GC1 CENSUS TRACT <br /> Owner's Name 04 Phone <br /> Address S <br /> City �CRLb/V <br /> Contractor's Name l 2 , 7 /p ^J 4 n R/ License 4190A)Phone z&Q 7 <br /> i TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /% DESTRUCTION /_7W � :srr <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> f <br /> Other. / / V <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r,�-- <br /> p PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLq, <br /> 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 �+T <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: Contractor i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / .State Work Done <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 "construct-ion.Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> L WELL DRILLERS REPORT of the well and notify them before puttingthewell in use. .. The above <br /> information is true to the best of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING D A F AL NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE`SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY_", DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTION <br /> INSPECTION BY DATE •I'NSPECTION 'BY TE5-. <br /> E H 1426 Rr v- 1_7L Oen <br />