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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&;OFFICE USE; 1/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/0-3G�/o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 5:-- <br /> �. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made ia. 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 c2a SLI , <br /> CENSUS TRACT <br /> Owner's Name " <br /> Phone , v <br /> Address <br /> City" <br /> Contractor's Name . . y o:,, Y- � -" License_ o2x3_�Jb_ vF� d <br /> - Phone <br /> TYPE OF WORK (Check): NEW WELL.-L-7 DEEPEN '/? RECONDITION DESTRUCTION /- <br /> PUMP INSTALLATION. / / PUMP REPAIR ,PUMP REPLACEMENT _17 <br /> Other 'I I F <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY <br /> $� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITQT R q j <br /> PROPERTY LINE - PRIVATE DOMESTIC WE v� PUBLIC DOMESTIC WELL `�,� <br /> INTENDED USE +.� .TYPE OF WELL <br /> — .1 CONSTRUCTION SPECIFICATIONS <br /> Industrial " <br /> �,__._ Cable Tool,- A� Dia. of Well Excavation - I <br /> Domestic/private • A Drilled Diaiof Well <br /> IjCasing <br /> Domestic/public ; Driven•4,�,.. Gauge of- Casing <br /> Irrigation ' - - Gravel Pa6k-1•� Depth_of, Grout Seal <br /> CathodicProtection� Rotary Type;of Grout <br /> Disposal Other Other Information= . <br /> Geophysical. SUrfa-de Seal Installed-1y;' <br /> PUMP INSTALLATION: ; ` <br /> Contractor <br /> Type .of Pump H.P. "f <br /> PUMP REPLACEMENT: <br /> Ll State Work Done � <br /> PUMP REPAIR: 4 / State Work Done t � <br /> DE& RUCTION OF WELL; Well. Diameter <br /> Approximate Depth : <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulationsof the San Joaquin'Local Health District <br /> and the State of 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 Health District a <br /> WELL DRILLERS REPORT of the well, and notify them before putting.the..weil 'in•use..:. The above <br /> information is true to the•best .af my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION- . <br />'RIOR TO .GRO TING AND-&)?INAL INSPECTION. <br /> SIGNED.'. : TITLE tl' <br /> DRAW PLOT PLAN ON REVERSE SID <br /> -FPR MAUMENT -USE ONLY <br /> PHASE I <br /> .Z'v�, <br /> L I rV 0r DATE <br /> APPLICATION ACCL <br /> /VR <br /> ADDITIONAL COMMWs r -- - — <br /> PHASE II GROUT INSPECTION PHASE III N INSPECTIN <br /> INSPECTION BY :DATE INSP�:CTTON BY DATE <br /> ' <br /> E H' 1426 Rev. 1-74 <br />