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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,z 4.990: <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 4 <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 the San Joaquin Local Health District. <br /> / V <br /> JOB ADDRESS/LOCATION �e�jn.,.CENSUS TRACT 0 ,6 <br /> / �... <br /> Owner's Name ' / '�� ; L Phone <br /> Address �. F F ` .�',� City <br /> 1 <br /> Contractor's Name License JPhone <br /> is <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DI-STANCE TO NEAREST: SEPTIC TANK Z:10 SEWER LIN ,S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINF,/6 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable.Tool Dia:. of Well, xcavation <br /> Domestic/private Drilled Dia. ofWelr.-Casing,.__/�? F. <br /> ome s tic/public Driven Gauge of Casing -� <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> L=� Cathodic Protection Rotary Type of Grout (� <br /> _Disposal Other Other Information <br />�a- "" Geophysical Surface'`Seal Installed By: " - <br />(PUMP INSTALLATION: Contractor <br /> Type of Pump a H.P. <br />`` <br /> PUMP,=REPLACEMENT: / / State Work Done 4e' <br /> PUMA' -.REPAIR: / / State Work Done <br /> DFS;TRUCTION OF WELL:' 'Wel:l^Diameter Approximate Depth <br /> .,; Describe Material and Procedure <br /> I-ha'7eby agree to co-mply'wztli aTlslaws and regulations of the San Joaquin Local Health District C <br /> an,,d% the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> rafter completion of my work on a new well, I will furnish the San Joaquin Local Health Distri_et <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above , <br /> information is true to the best oaf,'!ny A. owledge and belief. I WILL CALL FOR A GROUT INSPECTIONT <br /> PRIOR TO GROUTING D A FINAL INSPECTION, <br /> SIGNED - TITLE <br /> h Y (DRAW PIAT PLAN ..ON REVERSE SIDE) <br /> - - FORD ARTMENT USE ONLY <br /> )!Pl3ASE I A' ,- <br /> -19 <br /> ' APPLICATION ACCEPTED BY DATE <br /> A ITIONAL COMMENTS: <br /> ; y PHASE ,II ,GROUT INSPECTION PHASE III/ INAI, INSPECTIO <br /> IP-ECTION BY DATE INSPECTION BY DATE <br /> /11 IV Na P.? <br /> J*Mst4 k #0 W-,W, <br /> -H 1426 Rev. 1-74 �t _ <br />