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moi/ i <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT A , <br /> ] COE OFFICE 'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> PLICATION FOR WELL CONSTRUCTION DR PUMP PERMIT Permit No. " 2J 4 <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) , <br /> Application is hereby made to the San Joaquin Local Health, District for a permit to cons.truct .,-,, <br /> ,. <br /> and/or install the work herein described. This application is made in compliance with San Joaiqui�i <br /> County Ordinance No. 1.802 and, the, Rules, and Regulations of the San Joaquin Local Health,Disiricif. <br /> JOB ADDRESS/LOCATION 1_5`7 7 CENSUS TRACT <br /> Owner's Name Gt'�c�cXFPa Phone ,9 i <br /> Address47 44City -c .� °:J <br /> 5 <br /> CT <br /> Contractor's Name a-� d' <br /> License 2 <br /> 93 SSS/� <br /> ., <br /> % i€ <br /> TYPE OF WORK (Cheek) : 'NEW WELL-/_7 DEEPEN -./? RECONDITION / .,DESTRUCTION L7 <br /> PUMP. INSTALLATION / / PU14tP REPAIRf7 7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGt .P.IT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> ' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> r, Irrigation 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 /> - t � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. . <br /> PUMP REPLACEMENT: - :. /% State Work Dane <br /> PUMP .REPAIR: / / State Work Done - --.f <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 Distr ct <br /> and the StateofCalifornia pertaining to or regulating well"construction. Within FIUB81i A`fC <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health, Distii.e_t 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-beat of- my..knowledge and belief. I WILL CALL OR A GROUT PECTiC <br /> PRIOR TO GROUTING AND 4 414AL INSPEglog. <br /> SIGNED TITLE <br /> Coe <br /> MAAW: PLAN '0N kSE-SIDE -- -77 ,. <br /> .., �. ...�.. .,_. .. <br /> FOR DEPARTMENT ­USE-ONLY., <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II InSPBCTION PHASE II It'INAL INSPEC'T'IOW, <br /> INSPECTION BY DATE INSPECTION BY/n' DAft <br /> ER 1426 Rev. 1.74 {'. f V7b <br />