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T SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFTCE USE: 1601 E. Hazelton Ave. ,'` Stockton; Calif. " <br /> '~ Telephone: (209) 466-6.781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Al1d tz/ <br /> r THIS,PERMIT EXPIRES 1 YEAR 'FROM-DAA, ISSUED Date'Issued 5 .26.7r,L <br /> 4 7�g4 04rt--M-- 4Y . <br /> (Complete In Triplicate) ` . <br /> Application is hereby made to the San Joaquin Local Health Distti:ict. for.-a`permit to -construct <br /> and/or install the work herein described. . This .applicati-on-- is .made ift-..compliance with, San Joaquin <br /> County Ordinance No. 1862 and the Rules a>xd ,Regulations of 't:he San- Joaquin Local Health District, { <br /> JOB ADDRESS/LOCATION CENSUS'TTRACT �,205--130--2y <br /> Owner's Name 'An <br /> Phone <br /> Addressy <br /> Contractor's Namecense Liiw 3 <br /> Phone �� 7 c� <br /> TYPE OF WORK (Check): NEW WELL DEEPkl /_7 RECONDITION /_ DESTRUCTION-/7 <br /> PUMP INSTALLATION /. /- PUMP REPAIR 1_7 PUMP REPLACEMENT <br /> Other / / <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY ... � <br /> SEWAGE DISPOSAL FIELD'A. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE155MESTIC WELL PUBLIC DOMESTIC WELL J' <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled - Dia.hof We11;.Cas1ng' I <br /> Domestic/public Driven:_ I_! ..'Gauge"of.�Casing � <br /> Irrigation Gravel Pack 'Depths 6flGrout Seal I <br /> Cathodic Protection Rotary Type of�Grout i <br /> Disposal ' Other ''+'other Information <br /> Geophysicalze <br /> 0, SVrface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> _ a � <br /> PUMP �REPAIR:- - L-7 State Work Done <br /> F <br /> ES-TRUCTION OF WELL: Well Diameter ' A Approximate Depth <br /> Describe Material and Procedure <br /> i <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, 1 -will furnish the -San Joaquin Local. Healt:h. District a <br /> WELL DRILLERS REPORT of. the well and notify them before putting the'. well in use.. The above <br /> information is true to the-best.af my knowledge and belief. i WILL-CAI;L FOR A* GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDItaq. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r2 7_- 7 <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /,, ,_._. DATE Z- � <br /> E H 1426 Rev. 1-74 1-74 2M <br />