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Q res— ��a-Zy <br /> SAN JOA UIN LOCAL HEALTH DISTRICT / x <br /> FOR 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 here.in described. "This application.- is made in compliance with .San Joaquin <br /> County Ordinance No. 186 abd the Rules and Re tions of the Sa Joaquin."Local Health District. <br /> JOB ADDRESS/LOCATION 14 CENSUS TRACT ' <br /> owner's Name /V•u P/GrefeW <br /> Phone <br /> Address 3 FI City <br /> Contractor's Name , s- " /w License #g QT Phone <br /> TYPE OF WORK (Check) NEW WELL /Zf DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 _ M <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK/OL�' SEWER LINES/4M� --f PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINESQ' PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �` <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilledi `Dia. 'of Well. Casing <br /> Domestic/public Driven Gauge of Casing- , <br /> 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 /> PUMP INSTALLATION: Contractor +Y <br /> Type of Pump H.P.74 <br /> - t <br /> PUMP REPLACEMENT: / / State Work Done f. , <br /> PUMP .REPAIR: <br /> / / State Work Done -14 <br />)ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> - - - <br /> Des crib e-Material=°and Procedure --- <br /> C 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 />'iELL DRILLERS REPORT of the well and notify them before putting. the well in use. The above <br />_nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br />)IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />'RASE I FOR DEPARTMENT USE ONLY <br /> LPPLICATION ACCEPTED BY DATEkj <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE AL INSPECTION <br /> INSPECTION �BY �r DATE,,z/ INSPECTION BY DATE <br /> E H 1426 Rev. . 1-74 S� 6/7.7 2M <br />