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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�rO 'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />: Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. 2.1�_ <br /> f 41- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> k 7 �6 <br /> _ (Complete In Triplicate) 4, <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 Joaquin Local Health District. <br /> f <br /> JOB ADDRESS/LOCATION70 <br /> �' , <br /> 9 @ ENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address . � <br /> k city <br /> Contractor's- Name ca f -License # Phone -��; 0 <br /> K' <br /> - <br /> TYPE OF WORK (Check): NEW WELL l <br /> DEEPEN-/7.RECONDITION/_ -DESTRUCTION /77 <br /> PIiMP IiVS TALLATION / / PIMP REPAIR-/ PUMP ;REPLACEMENT <br /> Other-/t./ - <br /> DISTANCE TO NEAREST: SEPTIC`TANK 6$ SEWER LIES ' - j <br /> f' E <br /> P11111RIVY �- <br /> SEWAGE DISPOSA,L,rr�� 'IELD 6- CESSPOOL SEEP GE `PI ' <br /> PROPEVAT <br /> RTY-LINFI��#"PRIE DOMEfiIC WELD - OTHER 7 <br /> INTENDED USE PE OF WELL PUBLIC DOMESTIC WELL <br /> Industrial ' ; CONSTRUCTION SPECIFICATIONS # <br /> - ) Cable Tool t Dia. af�We1Z Excavation t <br /> Domestic/private Drilled 1. . <br /> Domestic/public Driven �L---s=Da :1of-.Well,Casing. <br /> Irrigation �- Gauge`of Casing p <br /> -Cat <br /> -Grave : V_k-, Depth of Grout Seal <br /> podic Protection rRotary� Type of Grout <br /> -Disposal _ <br /> Other Other Information <br /> Geophysical �. Surface Seal Installed By: S <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump -- --- _ H.P. <br /> PUMP REPLACEMENT: j//_ State Work Done <br />�PUMi'�:REPAIR• - -- <br /> ,:;� /� S to te;� " <br /> "-' Wa-rk <br /> MDone= <br /> 4ESIRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the an 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 Districtia <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 /> � <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � _ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PRASE II GROUT INSPECTION &7 RASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> _ DATE �- <br /> E H 1426_. Rev. 1-74 <br />