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d.: iN <br /> U41 SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOE: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED, Date Issued �l 76 <br /> (Complete In Triplicate) <br /> Application is hereby= de to- the San Joaquin Local Health District for a permit to construct <br /> I and/or install the work�;fherain 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 CENSUS TRACT <br /> r � f <br /> II Owner's Name - �Lt[ P 1 t"O'd.. - --, , ...,, . .,, ----- Phone ✓ <br /> Address Cit <br /> r <br /> Contractor's Name II' LicenseM Q Phone <br /> TYPE OF WORK (Check): NEW WELL /F' DEEPEN/7 RECONDITION /7 DESTRUCTION / <br /> 'UMP INSTALLATION "E/ PUMP REPAIR-/? PUMP REPLACEMENT /7 <br /> Other / <br /> I� <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Ism P. l <br /> SWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Fes, Som plc , <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing \' <br /> Domestic/public Driven Gauge of Casing i p <br /> j/ Irrigation r/ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �� Rotary Type of Grout . <br /> Disposal Other Other Information G�Uxea.�l <br /> Geophysical Surface 'Seal Installed B <br /> PUMP INSTALLATION:: ' Contractor <br /> Type .of Pump H.P. <br /> y <br /> PUMP REPLACEMENT: —/ State Work Done <br /> PUMP ItEPAIRz w `j .State Work Done r R <br /> DESTRUCTION OF WELL:, Well Diameter+ : Approximate Depth <br /> Describe Material and Procedure, <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 /> SWELL DRILLERS REPORT ofj 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 GALL :FOR A GROUT INSPECTION <br /> PRIOR TOG UTIN.G AN lFTNAL INSRECTION. _ r <br /> SIGNED TITLE <br /> II DRAW LOT PLAN ON REVERSE SIDE , • <br /> FOR DEPARTMENT USE- ONLY <br /> PHASE .I 7Y <br /> ' APPLICATION' ACCEPTED. BY I > l` DATE <br /> ADDITIONAL COMMENTS: 1. <br /> PHASE II GROUT INSPECTION t PHASE FIN SPECTION / <br /> INSPECTION BY DATE INSPECTION BY DATE - - h <br /> E H'1426 Rev. 1-74 4 2M <br />