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V <br />VV SAN JOAQUTN LOCAL HEALTH DISTRICT <br />FOS: FFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: 1209)Z466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />THIS PERMIT EXPIRES l YEAR FROM DATE'ISSUED Date Issued .9L__7_r___2e <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 ant Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION a��] �L <br />Owner's Name <br />Address .0 <br />Contractor's Name <br />I zxU CENSUS TRACT <br />Phone- <br />City <br />License l eydMPhone me -lG <br />TYPE OF WORK (Check): NEW WELL.-/21/ <br />ELL- DEEPEN'/7 RECONDITION %? DESTRUCTION /_7 <br />PUMP INSTALLATION -/7 _ PUMP REPAIR ' /_7 PUMP REPLACEMENT /% <br />Other %// <br />DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES • PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />abnritxan.v r.n. <br />INTENDED USE <br />Industrial <br />L--Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />Geophysical <br />PUMP INSTALLATION.- <br />PUMP <br />NSTALLATION: <br />PUMP REPLACEMENT: <br />PUMP ,REPAIR: <br />DESTRUCTION OF WELL: <br />.i s LJ.i\r, - rAIJ. VA16 ryrm <br />TYPE OF WELL <br />Cable.Tool <br />?/Drilled <br />Driven <br />Gravel Pack <br />.—Rotary <br />Other <br />Contractor <br />CONSTRUCTION SPECIFICATIONS V\1- <br />Dia, of Well Excavation f� <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal 4.5-3 <br />Type of Grout I <br />_ <br />Ocher Information .. <br />Surface Seal Installed By: <br />Type of Pump H.P. <br />Ll State Work Done <br />/7 State Work Done <br />Well Diameter Approximate Depth q <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 Realth 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 FOR A GROUT INSPECTION <br />PRIOR TO nUnttmTwr_ aun a VTVAT 7vanti+AmT�.. ., <br />PHASE I' ,4PA6v pr (_ <br />APPLICATION ACCEPT BY <br />ADDITIONAL COMMENTS: <br />rna*jm Lj. PHASE III FINAL INSPECTION <br />INSPECTION BY DATE - = INSPECTION $Y ATE <br />i •rue /D fYJrr G�- `/ <br />� 2M <br />E H 1426 Rev. 1-74 l�/� ���?�/4 <br />