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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE_USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> k PLICATION FOR WELL: CONSTRUCTION OR PUMP PERMIT Permit No. W_ <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 construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaqu- in Local Health District. <br /> JOB ADDRESS/LOCATION 1` _ k Ald",` 2-t-7- 120-0,7 <br /> r.41 CENSUS TRACT <br /> Owner's Name . -12&C-K Phone $ Z(o <br /> Address <br /> CitySC N <br /> Contractor's Name <br /> License Phone i'1 <br /> TYPE OF WORK (Check) . NEW WELL - i <br /> / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INST LATION /—/ PUMP REPAIR 17 <br /> F Other / / — <br /> r . <br /> DISTANCE TO NEAREST: SEPTIC TANK SD SEWER LINES ` PIT PRIVY y <br /> SEWAGE DTSPOSA, FIELD CESSPOOL/SEEPAGE`-PIT OTHER —= <br /> PROPERTY LINE"= PRIVATE DOMESTIC WELL:42-1 PUBLIC DOMESTIC WELL <br /> _INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> Industrial Cable Tool Dia, of Well Excavation <br /> 3 'l ?� <br /> Domestic/private Drilled Dia. of Well Casing a L� <br /> -Domestic/,pub e ,.--,Driven Gauge of�Casing,�_�. , <br /> Irrigation -�- <br /> g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout — G <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed BY: <br /> PUMP INSTALLATION; Contractor <br /> ti. Type of Pump H.P. <br /> PtTMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /�/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter # <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> an;t 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 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 TITLE <br /> DRAW PLOT PLAN 'ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY F <br /> ADDITIONAL COMMENTS: - __ DATE7,7 <br /> PHASE II GROUT INSPECTION PHA XI/FIN INSPECTION <br /> INSPECTION BY DATE INSPkCTION BY DATE I <br /> E H 1426 Rev. 1-74 3/76 2M <br />