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SAN JOAQUIN LOCAL HEALTH DISTRICT +.. � <br /> FOR(OFFICE USE: // 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1��-"4-'' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S--?-)7S- <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 �c L 13 ce T CENSUS TRACT <br /> Owner's Name S 4 S Eek L/ Phone c,�f- 2� (o 6—Z � <br /> Address (n r\ ��W� City <-;�t—ed <br /> Contractor's Name <br /> License # Phonik <br /> TYPE OF WORK (Check): NEW WELL/7 9AZ-7 <br /> /�7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLAT PUMP REPAIR /-7 PUMP REPLACmmd/ J <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIV STIC WELL PUBLIC DOMESTIC WELL �(1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONSPECIFICATIONS <br /> Industrial Cable To Dia. of Well Exca tion `v <br /> Domestic/private Drilled Dia. of Well Casi (� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 0th r ormation <br /> Geophysical Surface eal Inst ed B : <br /> AK <br /> PUMP INSTALLATION: Contractor <br /> 7 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Wori Done <br /> PUMP REPAIR: /7 State Wor one <br /> � � <br /> ,�ESeRUCTION OF WELL: Well ;iauldt"e"r Ap ste Depth <br /> Describe Mater al and Procedure ,�6 C ` 10 - O d- Fle c— <br /> (Tv Ccx1 <br /> I hereby agree to comply with all laws an regulations of the San Joaquin cal Health istrict <br /> and the State of California pertaining to or regulating well construction. Within FIFT EN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin strict a <br /> WELL DRILLERS REPORT of the well and notify them before putting- the. well in use.. The above <br /> information true to the-best of my knowledge and belief. LL FOR A GROUT INSPECTION <br /> PRIOR MCMUTXNG AND FIWZANECTION. <br /> SIGNED ZNLY <br /> D PLOT PLAN ON REVEDE <br /> R DEPARTMENT USE <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE "1 <br /> ADDITIONAL COMMENTS: &rl" ��- � <br /> PHASE II GROUT IN PECTION PHA$ZIII/FjVAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -% <br /> t E H 1426 Rev. I-74 1-74 2M <br />