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SAN JOAQUIN LOCAL -HEALTH DISTRICT - <br /> FOF}fOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 4 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 - D <br /> 4 , <br /> THIS PERMIT EXPIRES I YEAR .FROM DATE ISSUED Date'Issued 5=/ 7 -7� <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 R gulation f the San Joaquin Local Health District. <br /> rq 2 nc� C*—p o A,) o -V f4µ11 i i a <br /> JOE ADDRESS/.LO TION Q ' L s - S f a CENSUS TRACT <br /> Owner's Name Phone <br /> Address 1 w City L,.Sr'AZQ. �� � <br /> Contractor's Name !_ s�, kj- c2n r62 License # ,2 c)Phone <br /> ._.- ._ ,.-.- - �.,�„.,.... ,�--..-_ ..-�-.mac�' -.•':- r��`-;,�+.�' _.-f .s.a-.,,�,. _._. ,_, �� , ' -. r :- +r..4, <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 <br /> e PUMP INSTAL TION <br /> 4 REPAIR PUMP. REPLACEMENT /7 <br /> Other iI 2i <br /> I <br /> je <br /> S { <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES/ ti X PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD (CESSPOOL/.SEEPAGE PIT OTHER � <br /> aw. L PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE-OF--.WEL-L-----/- CONSTRUCTION-_SPECIFICATIONS <br /> Industrial + Cable Tooi� Dia, of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing �= <br /> Domestic/public Driven'` Gauge of Casing t <br /> . Irrigation i Gravel Pack Depth ofkGrout Seal <br /> Cathodic Protection ,Rotary Type of Grout <br /> Disposal Other Other information <br /> Geophysical --SurfacesSeal�Installed 'B ,: <br /> PUMP INSTALLATION: Contractor a *k <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUIdP :REPAYR¢`Y IF 5tate�Work Done �..,�,. . -..r <br /> ZES-T RUCTION OF WELL: Well Approximate PProximate Depth <br /> Describe Material and Procedure <br />! .! <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 /> WELL DRILLERS REPORT of 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 CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTINCI..MD A FINAL SPE ION. <br /> SIGNED TITLE <br /> }.t (DRAW PLOT PLAN -ON REVERSE SIDE <br /> I. <br /> FOR, 1 ARTNENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEP DATE l ` <br /> _ 1/7 <br /> ADDITIONAL COMMENT <br /> P IROUT :INSPECTION. P INAL INSPECTION <br /> INSPECTION ,DATE INSPEC BY DATE - <br /> 'I E H 1426 Rev. 1--74 ` 1-74 9m <br />