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I i-r <br /> C61X* / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O11VICE USE- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.VV <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 .Health District. <br /> JOB ADDRESS/LOCATION L -Ell CENSUS TRACT <br /> t <br /> Owner's Name - �lir.1 Z Le, /�� Phone <br /> a <br /> Address.: . City <br /> Contractor's Name-(fLicense # l 9 -7 Phone 4ak-70� <br /> F TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITI0N / / DESTRUCTION <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 /> t PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> �C Domestic/private: Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing tet' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> e Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 4 <br /> PUMP INSTALLATION: Contractor exv <br /> --Type of Pump H.P. <br /> PUMP / State Work Done L <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t 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 /> E after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLER'S�REPORT of the well and notify them before putting the well in use. The above <br /> informal ion is-true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPkCTION <br /> PRIOR TO GROUTING AND A FINAL IN E <br /> r SIGNED �` TITLE 4,1 <br /> DRAW LO PLAN ON R FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ - �- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION P jl, ALZINSPECTION <br /> INSPECTION BY . DATE INSPECTION BY DATE ��� <br /> r IV <br /> o/7J 2M <br /> E H 1.426 Rev. , 1-74 _ - - :,�; <br />