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<br /> 1/ SAN:JOAQUIN LOCAL,HEALTH DISTRICT •"D F
<br /> FOR•tOFFICE USE: // 1601 E. HazeltonAve. , 'Stockton, Calif. (/
<br /> Telephone,:c_-:'x:(,2'09) 466=6181
<br /> 7�
<br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit, Noo ,&/ W
<br /> TITS-PERMIT_'EXPIRES: 1 •YEAR:~FROM,1}ATE ISSUL'D , Date `issued .SSB !
<br /> •,�:�'s �Y�(Complete.<�n�Txiplicate} _= ter: �a }.� ur ,
<br /> Application` U hereby made to the San.Joaquin lLocal.:Health,.Disttitt-,-for a`pelt to, construct j
<br /> and/or install .the work hearein .described. ;,,This sppiication is,-,made3 in-.compliance"'with San Joaquin
<br /> County Ordinance 'No. 1862 and the Rules land Regulations---ofthepzSanrJoaqu tt Local' stealth=District.
<br /> JOB ADDRESS/LOCATION f �_�� �� ���:.A , r".� r !� :;;r. _>:. - �•��
<br /> ENSUS`.TRACT .
<br /> Owner P a`Name f ,� Phone3/'�P3
<br /> Address �� �� ti.�.. m ..,. ...,_. .. > . ,City
<br /> .�
<br /> Ale
<br /> Contractor's Name f _ License # rZ� Phone gyf "�y
<br /> TYPE OF WORK (Check): NEW-WELL /)-,-7; DEEPEN /_ RECONDITION'-fT DESTRUCTION ./7 '
<br /> e PUMF�"''INST LATION / /_PUMP REPAIR. -/ 7 PUMP .REPLACEMENT._...!
<br /> Other ./�/ - ,
<br /> lad
<br /> I
<br /> ;l. V 0
<br /> ,
<br /> DISTANCE TO NEAREST; ' SEPTIC TANK SEWER LINES PIT. PRIVY.
<br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER
<br /> r
<br /> PROPERTY. LINE - PRIVATE -DOMESTIC WELL` " .PUBLIC DOMESTIC'WELL
<br /> INTENDED USE ,, TYPE OF WELL _ ...,,-,CONSTRUCTION SPECIFICATIONS . _
<br /> Industrial "w,.� . Cable Tool `� �Dia. of Well Excavation
<br /> Domestic/private Drilled
<br /> Dia.--of Well Casing / y
<br /> Domestic/public, ' Driven Gauge„of Casing ,
<br /> X Irrigation _ Gravel Pack . Depth of Grout Seal
<br /> Cathodic Protection Rotary.- - • TypeY°af 'Grout
<br /> Disposal Other Other, nformation
<br /> Geophysical Surface..Seal Installed By:
<br /> ,M
<br /> cr:N,,, 4
<br /> :r.
<br /> UMP INSTALLATION: Con'trac rt I =
<br /> Type-�of'Pump- w ” ..
<br /> . ,
<br /> H.P.
<br /> rt
<br /> PUMP REPLACEMENT: / / :3: State Work Done
<br /> PUMP :REPAIR: /7 ; State Work Done,
<br /> ES;TRUCTION OF WELL: Well:!,Diameter r 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 Califo:rnia:lpertaining 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-best-of my knowledge and belief: I `WILL' CALL FOR A GROUT INSPECTION:
<br /> PRIOR TO GROUTING AND A FINAL INSPECTION.
<br /> SIGNED .1. TITLE
<br /> -,(DRAW- PLOT PLAN-ON REVERSE` SIDE
<br /> �;. OR DEPARTMENT _USE_ONLY
<br /> PRASE I 1 ,
<br /> APPLICATION ACCEPTED BY ' �`' - "� , DATE
<br /> ADDITIONAL COMMENTS_
<br /> -PRASE II GROUT INSPECTION , PHASE III/FINAL-.INSPECTION
<br /> INSPECTION BY "DATE INSPECTION BY , DATE Z(j YA 7
<br /> }� E H 1426 Rev. 1.-74 A
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<br /> :,. :., 1-74 2M -
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