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it SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo—giOFFICE USE: 1601 E. Hazelton Ave. ,, Stockton, Calif. ( /'j/►J <br /> Telephone: (209), 466-6781 's <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.:, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> III (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 3oaquiv� <br /> County Ordinance No. 1862 a the Rules and�Regulations of the San Joaquin Local Health District. <br /> JOB ES /LOCATION a GQ� 2 Q� r�OC14wolllm�nsus TRACT <br /> Owner's Name �(! Phone . <br /> Address " ;I� City <br /> Contractor's Name X License Phone,/��jZ�l'. <br /> iM. <br /> TYPE OF WORK (Check) : NEWryWELL / DEEP /_7 RECONDITION /_� DESTRUCTION J <br /> PUMP INST LATION / PUMP REPAIR /� PUMP REPLACEMENT /7 <br /> Jk <br /> Othei / / °" yVA <br /> DISTANCE .TO NEAREST: SEPTIC TANKSEWER LINES -1-PIT PRIVY <br /> SEWAGE DISP SAL FIELD - -mak /SEEPAGE PIT Z �`6THER <br /> --- PRDP-ERTY-LINE RIVATE--DOMESTIC-WELL- PUBLIC^DOMESTIC-WELL- <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> " <br /> --Industrial Cable Tool Dia. of Well Excavation <br /> Aomestic/private 777--Drilled Dia. of Well Casing <br /> Domestic/public• ji.2- " r . Driven Gauge of Casing 2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -V—Rotary---- '. Type of Grout <br /> Disposal Other _ T ',Other information <br /> Geophysical9 �,, Surface`5eal Installed By: <br /> PUMP INSTALLAT,10 ': Contractor <br /> Type of Pump H.P. <br /> r PUMP REPLACEMENT: t <br /> I k3 <br /> 113, <br /> j / / State Work <br /> PUMP :REPAIR: +` /7�IState Work Dane <br /> I I � . <br /> PES•TRUCTION OF WELL: Well Diameter , Approximate Depth <br /> f Describe Material and Procedure <br /> i hereby agree to comply withaa-.l--laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on .a new well, I will' furnish the San Joaquin Local Health District a <br /> WELL DRILLERS, REPORT of the well and notify them before putting.the..well in use.. The above <br /> information is true to the'hbest of. my.knowledge and -belief. I WILL CALL FOR A -GROUT INSPECTION <br /> I PRIOR TO GROUTING AND A FINAL INSPECTIO ,, <br /> SIGNED <br /> D PLT LAN ERSE SIDE <br /> �DEPAR T USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED `BY�i DATE 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE-II GROUT INSPECTION PHAS II FINAL INSPECTION <br /> INSPECTION BY 'II' DATE INSPECTION- BY DATE <br /> '1 E H 1426 Rev.'_I-i4' � � - ' _ T 1-74 2M <br />