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} ,G SAN JOAQUIN LOCAL HEALTH DISTRICT fi] <br /> FO$rOFFICE USE: b 1� 160I E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 _ <br /> iN (Complete In Triplicate) <br /> Application is hereby made to the Sen 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 / S 5'0 M S 7c CENSUS TRACT , <br /> r ai <br /> Owner's NameA 12 1/ /N L Z Z/ Phone 9�f-✓?�(�� <br /> Address /e o a N City <br /> k <br /> Contractor's Name .S/q A'1 License # Phone <br /> a , <br /> TYPE OF WORK (Check)-: , NEW WELL /? DEEPEN '/? ,RECONDITION -/? -DESTRUCT-ION.- �-- <br /> �-•PUMP;FINSTALLATIUN / j PUMP REPAIR /7 PUMP REPLACEMET /7 <br /> f r O then <br /> ob <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WALL <br /> INTENDED USE `TYPE OF WELL CONSTRUCTION SPECIFICATIONS Cn <br /> Industrial Ih CableJTool t Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public a Driven Gauge of Casing <br /> Irrigation -5 T Gravel- Pack Depth of Grout Seal <br /> Cathodic Protection ,Rotary Type of Grout' <br /> Disposal Other =+ Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor"l,:-, + . . �-•- <br /> �, <br /> Type of PUMP H.P. <br /> PUMP REPLACEMENT: ' ST' <br /> / / I tate Work Done <br /> Pte' /? I State f Work Done <br /> S�TRUCTION OF WELL: I� Diameter _ 57 eO 1 �XiST�� 6���o��� <br /> Approximate Depth a , <br /> Describe Material and Procedure S p <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California'rpertaining 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'*ell and notify them before 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - -7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTJNSPECTION PHAS FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B ATE <br /> Y <br /> t4 E H 1426 Rev. ]-74 !� 1-74 2M <br />