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SAN JOAQUIN LOCAL HEALTH DISTRICT, S <br /> FOR OFFICE USE: 1601- E. Hazelton. Ave. , Stockton, Calif. - <br /> Telephone: <br /> alif.Telephone: {209} 466--6781 - <br /> APPLICATION <br /> 66=6781 -APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueyAR 14 ?978 <br /> (Complete In Triplicate) <br /> t 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. 1.862 and the Rules and .Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION Zfij �'� Q.�a R,, n►y CENSUS TRACT <br /> Owner's Name (� � A rC A 4V C- [�v�� 'C ,, ._. __- Phone,, '1_3 r <br /> -- - -- tit . . <br /> Addresso I t — <br /> T� �i � `�( �a�"5F � T .. - T City /Ll�r cA <br /> Contractor's Name 0m, ilit S'/1 - _ 12c1m s'u ^r r,-g - License #2-�, Phone <br /> TYPE OF WORK (Check) : NEW WELL / -/ ,'-DEEPEN / J RECONDITION; / / DESTRUCTION: / <br /> Y - PUMP -INSTALLATION' 7��PUMP. REPAIR /-J PUMP REPLACEMENT /� - ' O <br /> k Other /_7 — <br /> dl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 'LINES .0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD •` , - kk CESSPOOL/SEEPAGE PIT OTHER U <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL � . , CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool°` . . Dia. +of We11 Excavation <br /> t�Domestic/private # Drilled Dia. 'of Well Casing <br /> Domestic/public ! Driven Gauge- of. Casing <br /> Irrigation Gravel Pack Depth'of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other rF Other Information <br /> Geophysical Surface iSeal Installed By: <br /> ' uk <br /> PUMP INSTALLATION: Contractor _�►u f ip ed <br /> Type of Pump h .�rt-f�l �' 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 construction.- Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the. San Joaquin Local Healsih District a <br /> i WELL DRILLERS REPORT of the well and notify them before putting--the well in use.. Tte above <br /> information is true to the best of- my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO ROUT AND A FINAL INSPECTION. <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 /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B ATE A ' <br /> E H 1426 Rev. - I-74 <br />