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SAN ;JOAQUIN:LOCAL HEALTH DISTRICT <br /> FORrOFFIGE USE: 160l .E, Hazelton Ave. , Stockton, Calif. <br /> E Telephone: ..: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES;1. YEAR°FROM,DATE,ISSUSD 'Date issued 5'r 7­244 <br /> (Complete 'ln Triplicate) _ <br /> Application is hereby made to the Safi Joaquin Local -Health^.Disttfct'•for a perdu to construct ' <br /> and/or install the work herein_ described. ; .This-application, i.slmade,in compliance-,with San� Joaqudn1 <br /> rCounty. Ordinance No. 1862 and the Rules and-Regulations,,of the,San Joaquin Local Health District <br /> JOB ADDRESS/LOCATIONL TRACT : J <br /> . CENSUB <br /> 00 <br /> Owner's Name Phone_: <br /> ax <br /> 1 <br /> Address _. _. _ city <br /> 6 , yon <br /> Contractor's NameLicense # a7a Phone <br /> ' 1 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN -/-7 RECONDITION /7 DESTRUCTION /7-' <br /> PUMP INSTALLATION /� PUMP REPAIR /� PUMP. REPLACEMENT <br /> Other / <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 WELD, ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS ' <br /> Industrial _ _ Cable Tool Dia. of .Well Excavation -- <br /> Domestic/private Drilled Dia. of Well Casing ,r <br /> Domestic/public Driven Gauge •f, Casing.. AZA <br /> . 31e jZoA <br /> Irrigation 'Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of 'Grout <br /> Disposal Other Other Iafarmatf,on . ' <br /> Geophysical Surface Seal Installed„ By: <br /> PUMP INSTALLATION: Contractor ..{ <br /> Type of Pump H:P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> P.UMP :REPAIR: /? State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> scribe Material and Procedure i <br /> I hereby agree to comply with all lawal' andkitegulations of the San Joaquin Local Health District , <br /> and the State of California pertaining to or regulating well :construction. Wiihiii 'FIFTEEN DAYS ' <br /> after completion of my work on a new well, I will, furnish the San .Joaquin Local Health District's <br /> 'WELL DRILLERS REPORT of the'.well and notify them before puttingthe- well in-use.. The above; i <br /> information is true to -the best of my .knowledge 'and belief. I WILL CALL FORA GROUT INSPECTION ! <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DJLAW PLAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I - <br /> APPLICATION ACCEPTED B 7 .s' DATE .S 7 <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE JIUFINAPaINSPECTION <br /> INSPECTION BY <br /> DATE , INSPECTION BY ATE <br /> 1 E H 1426 Rev. 1-74 I_7A lu <br />