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f <br /> FOR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R OFFICE UUSE: 1601 E. Hazelton Ave. , Stockton, Calif. G�pS`r �'�, <br /> C Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _1,(,�4J <br /> �I <br /> 4 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) uei - �_1 <br /> a w <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 Joa uin Local Health District, <br /> JOB ADDRESS/LOCATION. . � �/ <br /> �i7Ci s , AV <br /> oe <br /> CENSUS TRACT <br /> Owner's Name <br /> hone <br /> Address,',,,.' 2 <br /> City <br /> Contractor's Name i �` <br /> 4 <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/_7 RECONDITION /7. DESTRUCTION /7_ ~ - - <br /> l PZIMP INSTALLATION / I PUMP REPAIR Ikj <br /> f Other /L j SUMP REPLACEMENT <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES7r <br /> SEWAGE l7ISPOSAL FIELD PST PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> Industrial TYPE OCab12 WEEeLTool G CONSTRUCTION SPECIFICATIONS <br /> ­. Domestic/private Dia. of Well �Excavat <br /> /private- Drilled ion <br /> Dia. of Well �Gasing <br /> -.�,. Dome�t�c/pu_bis Driven <br /> w.. Irrigatioa ~' `� Gauge' of Casing <br /> n---- Gravel Pack Depth; of Grout Seal <br /> Cathodic-Pr-o•tec•t4-OR----_ <br /> ^,_„Disposal �Raiar3r a of Grout <br /> �`_� -�. <br /> ,Geophysical .,_.. Other Other; Information <br /> Sukface Seal Installed By: <br /> PUMP INSTALLATION: Contractor € <br /> Type o Pump <br /> ,� / i H.P. <br /> PUMP REPLACEMENT,:., Is• <br /> / / tState Work Done G "� <br /> aPUMPZtEPAIR; State"'"Wark - `•! <br /> ES�TRUCTION OF WELL; Well Diameter „ . <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to cam 1 with <br /> comp .y all laws and regulatious�of the San Joaquin Local Health District ! t <br /> and. the State of California pertaining to or regulating weil �construction. Within FIFTEEN DAYS .' <br /> after completion of my wank on a new well, I will furnish the San Joaquin Local <br /> He <br /> WELL DRILLERS REPORT of the well and notify them before puttinthe..well in.use.. Theh District a <br /> g. <br /> above <br /> information is true to the-best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT G D A IN INSPECTION. <br /> SIGNED <br /> TITLE <br /> ---------- a--- _r� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USEONLY f <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE - L7 <br /> PHASE II GROUT INSPECTION PHASE .III FINAL ,INSPECTION <br /> INSPECTION BY DATE INSPECTION .BY ,E/ <br /> ... . - f DATE <br /> E H 1426 Rev. 1-74 } <br />