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�✓ Q � <br /> j� <br /> fF_ 7FICE-U`SE_-- <br /> ee-4:^lplel- SAN JOA UIN LOCAL .HEALTH DISTRICT -4 77 1' <br /> O 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1a <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued "-7o <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 Joaquin Local Health District. -) <br /> JOB ADDRESS/LOCATION +� b7 CENSUS TRACT <br /> Owner's Name ,CC Z &2 Phone <br /> Address Afl"17-f City <br /> 4 <br /> Contractor's Name License # Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEWWELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATIONI / PUMP REPAIR/ / PUMP REPLACEMENT /� } <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,S <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL p- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J•, <br /> Industrial ,i Cable Tool Dia. of Well Excavation <br /> Domestic/private '9 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection " Rotary Type of Grout ` <br /> Disposal l Other Other Information <br /> Geophysical Surface Seal Installed By: 046,XZA- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 5'u H.P. ` r - - <br /> Pt4T REPLACEMENT: / / State `Work Done ' <br /> PUMP •.REPArR.� . ,;-/_._/_.,,State`Work Done <br /> I` <br /> Approximate Depth <br /> DES"TRUCTION OF WELL: Well Diameter �,% T <br /> T <br /> Describe Material'%and+-Ptocedure <br /> 1 hereby :,agr to comply_with. all laws andnregulatlon `s of the San Joaquin Local Health District <br /> and the Statefof California per.ta�ining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new we'1°1,""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 /> j information is true to ;thl&best of. my knowledge. and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROJ41NG OD A FINAL I CTS N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Ij GROUT INSPECTION PHAS: III/FINAL INSPECTION <br /> INSPECTION BY Il0 DATE INSPECTION BY DATE <br /> : 1 2M <br /> E H 1426 Rev. 1-74,,.:— <br /> - - <br />