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4• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk 0?�FICE., S 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �'� "� . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S� <br /> < r I <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 Joaquin Local HeaaltDistrict. <br /> JOB ADDRESS/LOCATION �f ��l �SC�o.sJ Gam; CENSUS TRACT <br /> L <br /> Owner's Name '� CI -� Phone ?.d?`- Q��d <br /> Address City �.CJ <br /> . Contract-or-'-s Name License # yAZMZPhone 9 �g <br /> . TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION_/ / DESTRUCTION /� — <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES 3 ` PIT� PRIVY --f` <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PIT _�,.a,--OTHER T <br /> PROPERTY LINE.9d PRIVATE DOMESTIC WELL 3a2e' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Y Industrial Cable Tool Dia, of Well Excavation " <br /> ri <br /> Domestic/private Drilled Dia, of Well Casing p <br /> Domestic/public Driven Gauge of Casing a" <br /> Irrigation X Gravel Pack Depth 'of Grout Seal �f¢ <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : U�S�G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - - <br /> PUMP REPLACEMENT: / / State Work Done - � '• _ _-_��_ �-_ _ -y.- - .�-u- -- + �` _-_ <br /> PUMP--REPAIR: / /-6-State'`Work-Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <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 FI AL INSPECTION. <br /> t SIGNED <br /> TITLE , �- .P_i SP- — <br /> (DRAW PLOT PLAN ON <br /> k FOR DEPARTMENT I AE CSNLY <br /> PHASE i <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE .II GROUT INSPECTION ,)-THAS0ti11 .I./;�;IN INSPECTION <br /> INSPECTION BY DATE INSPECTION;-BY + ' ��°`" . ` '- DATE Y( <br /> b/71 _ 2M <br />