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Cf" SAN JOAQUIN LOCAL HEALTH DISTRICT '- <br /> FOE-OFFICE USE; 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �?-ld�f0/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8"- s <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 �� /,7`' CENSUS TRACT <br /> Owner's Name Phoneme -3120 <br /> Address City 6 <br /> f <br /> iContraQtor's Name ' M022 4F� '�_20,0 <br /> , License' # �7"'Phone add <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7AL <br /> PUMP INSTALLATION —Pr/ 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 ,ICONSTRUCTION SPECIFICATIONS f Q <br /> Industrial - Cib3ekTool . - . - -Dia. of Well Excavation <br /> -Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public„- - -D.riven_ Gauge of Casing— <br /> Irrigation <br /> ' �- -- - <br /> Irrigation Gravel Pack Depth of; Grout Seal (\1 <br /> Cathodic Protection Rotary Type of-Grout <br /> Disposal Other Other Information <br /> GeophysicalSurface'-Seal Installed By: <br /> tea, .r'_ <br /> PUMP-INSTALLATION: Contractor <br /> type of Pump H.P. f <br /> PUMP REPLACEMENT: -y / / .r State Work Done <br /> PUMP .REPAIR: `-State-Work Done <br /> DESTRUCTION OF WELL:4 . Yell' Diamet r ;.". Approximate Depth <br /> `Describe Material and ,Pxocedure <br /> s <br /> I hereby agree to comply with .all1laws and regulations of the San Joaquin Local Health District <br /> ` and the State of California".pertaining to or regulating we11 •construction. 11 Within FIFTEEN DAYS <br /> [ after completion of my work oni,,a new well,, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notifytthem;befo're '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 GROWING AND 4 FINAL INSPECTION. <br /> I SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> t PHAS E I 3 <br /> 1APPLICATION ACCEPTED BY DATE <br /> [ ADDITIONAL COMMENTS: , <br /> PHASE II ROUT INSACTION PHASE III/F AL INSPE 0 <br /> INSPECTION BY __ADATE INSPECTION BY _,Fl & DAT `- <br /> jo <br /> E H 1426 Rev. 1-74 U 1 - 2M <br />