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r • it <br /> - e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> XOR iOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i <br /> Telephone: (209) 466-67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,5 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued --2r-.7f <br /> j <br /> (Complete In Triplicate) 1-3 1- 12-0-vX <br /> Applicdtion 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.- <br /> ., ,1862 and the Rules and Regulations of the S Joaquin Local Health District. <br /> MR(PtJ > !6Z 4"y l'if S > • <br /> JOB ADDRESS/LOCATI / CENSUS TRACT <br /> ey <br /> Owner's Named �' �a '�'� Phone � � F <br /> Address <br /> Contractor's Name U � S - License /� 7`4hon41K4'5 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN%� RECONDITION /_� DESTRUCTION, <br /> PUMP INSTLATION /-J PUMP REPAIR /7 PUMP REPLACEMENT 17 <br /> Other /-7 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFXrZT10S <br /> ' Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing_ <br /> Domestic/public Driven Gauge of Casing '-, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -A Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _�"__ <br /> PUMP INSTALLATION% Contractor <br /> Type of Pump 4t&e� 6 t H•P. i <br /> -00 <br /> PUMP REPLACEMENT: tate' Work Done <br /> CE 1 vl St t a <br /> -PUHP <br /> :REPAIR;_-�� _ - - �State'Work Done <br /> PESIRUCTION OF WELL: Well Diameter ApprxivAt� h & <br /> Desc ibe Matpriayi an Procedure 7- o <br /> .Ara YY'" tp <br /> I hereby agree to comply vl th all laws an 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 completliAzn of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL RE ORT e ] and notify them before putting.the,.well in.use.. The above <br /> infarmati is t 4N ?WA <br /> t/af my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTI NSPECTION <br /> SIGNED �, TITLE <br /> -'< (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENTUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 2 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE -�Sr ...INSPECTION BY DATE Z-z G <br /> 1 E H 1426 Rev. 1-74 '' ) : : 1-74 2M <br />