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SAN JOAQUIN LOCAL IIEALTH DISTRICT ,. <br /> R. �FFXE C­E1 E; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION GR -PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r p. . (Complete In Triplicate) /?U-- Or <br /> App' cat on °h eb made"t �- <br /> y °o�t�i�e �an 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 'Jopquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joa�u g Local 4ea.1th District. <br /> d f tl 0 01% S•s�?w� �eh_,eoV �'S.,Ts• se" <br /> JOB ADDRESS/LOCATION <br /> - iI r e CENSUS_AFTRAM er , <br /> Owner's Name TRaG.y_ CAL,";-.- �•V •T4, <br /> Phone $• <br />` Address City /�-•N, i�•,L <br /> Contractor's Nam ? �,' License Phone <br /> , t <br /> TYPE OF WORK (Check) : �/ ,EN RECONDITION /_7 DESTRUCTION /_ <br /> PUMP REPAIR / / PUMP REPLACEMENT <br /> _�sem•:�::,-,_,_-. <br /> DISTANCE TO NEAREST: SEPTIC TANKER LINES PIT PRIVY <br /> SEWAGE DISPO*- P&TiE <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF- WE19L CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> sr <br />- -o4 '_Domes-tic/pub1 c .•:: �,.�F.� Driven ti Gauge of Casing <br /> =,frrigation L,-_'-Gravel Pack Depth of Grout Seal 47� <br /> ,_,,—CathodicPzotection �� Ro.tary FType of Grout MqAf=&1 - <br /> Disposal -�� Other Other Information <br /> Geophysical Surface Seal Installed By: o <br /> PUMP INSTALLATION: Contractor <br /> TYPe of Pump - . .- 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',ot 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 Healti District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well. in .use.. The above <br /> information-is a- to -the best"of my.knowleage-and"`belief. iI WiLL CAL FOR 'A�Gr I SPE TION <br /> PRIOR TO GRQU7 kNIJ A FINAL INSPECTION. e . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY- f DATE <br /> ADDITIONAL COMMENTS: <br /> ""' PHASE II GROUT INSPEC ION PHASE III/FINAL INSPECT,I@N -~ <br /> INSPECTION BY DATE INSPECTION BY DATE i <br /> /s���✓/O� 1, <br /> C 1/7? - 2 <br />� E H 1426 Rev. 1-74� , <br />