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y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209)# 466-6781 <br /> APPLICATION FOR WELL: CONSTRUCTION OR PUMP PERMIT. Permit No..—) <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 Jo4quin I <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. f <br /> E <br /> JOB ADDRESS/LOCATION AZ 0 D�'7tr�rS /Po cl CENSUS TRACT <br /> Owner's Name olivedgri Ff-e- rV 'fru` Phone 6V 7 795 <br /> Address <br /> City <br /> Contractor's Name ,j o Sv jo I License1.2.540103 Phone Y7V 34 <br /> STYPE OF WORK (Check) : NEW WELL/L-�- DEEPEN ;/—/ RECONDITION /% DESTRUCTION /-7 - <br /> PUMP INSTALLATIQNoPUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other. / / — 7Q <br /> At' <br />', DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL f CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia:",of We 11 Excavation 700 � <br /> Domestic r f "of,Well Casing �!-5/�i _ _ <br /> Domestic/public Driven Gaug of Casing <br /> Irrigation Gravel Pack Depth4Zf- Grout Seal <br /> Cathodic ProtectionRotar T e .o'f GroutY. __ `� <br /> y t __ _- .. YP . iyt�A.r <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: , ,- ito <br /> PUMP INSTALLATION: Contractor - - .J�; <br /> Type of rump - <br /> PUMP REPLACEMENT: State State Work Done � <br /> j UMP.REPAIR: ,__ ./�._/.,. State_Work.,Done <br />',DES-TRUCTION 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 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 /> (DRAWIPLOT PLAN ON REVERSE SID <br /> ,FOR DEPARTMENT USE ONLY <br /> PHASE I lZZZ <br /> APPLICATION ACCEPTED BY DATE + l4 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT ASPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 2M <br />