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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR­OFFICE USE: ' <br /> .._,1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 . 'Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE - <br /> . ISSUED Date Issued , ,y-2 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> application is made in compliance with San Joaquin <br /> and/or install the work herein described. This <br /> County Ordinance No, 1862 and the Rules and Regulati:oiis'"a£ .the. San Joaquin Local Health District. <br /> I 1863 .9 . o CENSUS TRACT <br /> JOB ADDRESS/LOCATION �]�/r-5 <br /> Phone <br /> one <br /> Owner's Name /yG�C� ��` �O^ � �-- :_ i <br /> City <br /> Address <br /> License 1j,;Z"7 Phone <br /> Contractor's Name y <br /> t. <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / <br /> RECONDITION /_/ DF ION /? <br /> PUMP INSTALLA ION PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Cj SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> gPRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> PROPERTY LINE <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ ' <br /> Industrial <br /> Cable Tool Dia. of Well Excavation /a <br /> Well Casing <br /> Dia. •f L <br /> Domestic/private Driven a Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal '-5 d th <br /> Cathodic Protectiono.• .Rotary Type of Grout <br /> Disposal Other Other Information' <br /> p 'Surface Seal Installed By: m <br /> Geophysical. _. � - <br /> t PUMP INSTALLATION: Contractor l <br /> s Type of Pump H.P. / <br /> t <br /> PUMP REPLACEMENT: . 7 State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> w y�pr aH f�- S. <br /> reb agr�e to comply with all la and reg ion of t an i L al alt ict <br /> and the State of California pertaining to or regulating well''construction. Within F DAYS <br /> Kafter completion of my work on a new well, I will furnish the San Joaquin Local Heal h District a <br /> WELL DRILLERS REPORT a e w 11 and notify them before putting the .well in use, The above <br /> information is tru o. the be my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO,GROUT AL INS P IO TITLE <br /> I SIGNED <br /> • DRAW�fL—t'.1f PLAN ON REVERSE SIDE) <br /> . {OR ,PARTMENT USE ONLY <br /> PHASE I ® f AT /(J 5' 76 <br /> APPLICATION ACCEPT BY o' <br /> ADDITI NAL CO p INSPECTION <br /> E DATE <br /> OUT INSPECTION <br /> DATE �- INSPECTION B - / <br /> T y 1 d , v �T �o <br /> --7�,, <br /> E "H 1426 Rev. 1-740 ;� -" <br />