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*� �✓ SAV JOAQUIN LOCAL HEALTH DISTRICT <br /> F0%, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> i, (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 Joaqui°. <br /> tCounty Ordinance No. 1862 and the Rule and ulati34p-k- <br /> of the Sa Joa u n Local Health District. <br /> � . � X2-0 � ���� � <br /> JOB ADDRESS/LOCATION T'41 k G V LD T N T �.lCENSUS TRACT <br /> Owner's Name 00 Phone , Y66 <br /> Address N. �a�a-� i� <br /> k city . S�"aCi� 4"% <br /> Contractor's Name -�-: 3 t <br /> '�-�a�� � ., .���.., .,. License ��'oL�' Phone ��'t�-Y�D- <br /> t TYPE OF WORK (Check) : ,.NEW WELL/? DEEPEN /_7 RECONDITION /-? DESTRUCTION f7 <br /> " 'PUMP AL <br /> PUMP INSTLATION / PUMP REPAIR /? PUMP REPLACEMENT 17 <br /> }F „Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> - SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEAPIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL (� <br /> INTENDED- USE i! TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation' <br /> Domestic/private . Drilled _ Dia. of Well Casing <br /> ' D6mestic/public Driven ,, Gauge of Casing <br /> Irkigitiou i, Gravel`Pack°°' < Depth of Grout Seal <br /> "Cathod.ic`Pro;tect on Rotary Type of Grout <br /> Disposal• ",. Other Other Information <br /> f ,Geophysical ` . _ . _ :-w _ Surface Seal I st <br /> - - -. alleilB <br /> PUMP INSTALLATION: . ;Contractor [ >. ,tf <br /> ,Type of_Pump - z H.P. <br /> PUMP�REPLACEMENT: `; ;,/ / State Work Done <br /> PUMP .REPAIR: State .Work Dane, {1 <br /> q DESTRUCTION .OF WELL: Weil Diameter <br /> Approximate Depth <br /> :Describe Material and Procedure <br /> hereby-agree� <br /> I -a ree to com 1 yw Y g p y iCh al-I-laws,-and regulations of the San Joaquin Local Health District <br /> I and the State of CaVifornia pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> L - <br /> after completion of uiy•work on a new, well, J,•wil.l furnish the San Joaquin Local Health District a, <br /> WELL DRILLERS REPORT of the well"an}d4.notify them before putting.the..well. in.use.... .The above <br /> information is true 4.to .:the best of my...krr► ledge and belief. I WILL CALL FOR-A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND" FI. & INSPEC . <br /> SIGNED TITLE <br /> z� DRAW PLOT PLAN ON REVERSE SIDE ' <br /> F R DEPARTMENT USE ONLY <br /> PHASE I "" <br /> APPLICATION' ACCEPTED B DATE . <br /> ADDITIONAL COMMENTS: <br /> ' PHASE 11 GROUT INSPECTION PHA II FINAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1. <br /> E H 1426 Rev. 1-74 r` h/7q 2M <br />