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T SAN -TOA ' 1N LOCAL° HEALTH DISTRICT <br /> FIJfs� 1 FPI F FUS - �. <br /> r, y 1601 E. Ha elt 'gf Ave, ; Stockton, Calif. <br /> Telephone: (2093 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per �tj , . <br /> THIS PERMIT EXPIRES 1•YEAR FROM DATE ISSUED <br /> w Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin, Local -dealth' 'District far a pe,rmiti to con6truct ' <br /> and/or, install the work herein described. This application is made in compliance,, with San ,.Iggqu'. <br /> County Ordinance No. 1862 �nd the Rules and Regulations of the San Joaquin-,' Local. Heal,th District" <br /> JOB ADDRESS/LOCATION CENSUS TRACT _ <br /> Owner's Name _f✓ _ /TG L r £ /Xy-'. �___r__�� <br /> r Phone <br /> Address �5n 63)� <br /> City <br /> Y--:- <br /> Contractor's Name0.y License Phone . <br /> TYPE OF WO�RKheck) : NEW ELI; ` / DEEPEN <br /> _/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP: INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT; /-7 <br /> s A } <br /> Othe <br /> 1 Y t <br /> DISTANCE TO NEAREST: SEPTIC TANKO SEWER LINES.-== PIT PRIVY er <br /> GI <br /> SEWAG' -DISPOSAL FIELD '110 Q CESSPOOL/SEEPAGE :PIT <br /> OTHER- - y <br /> PROPERTY LINE IT PRIVATE DOMESTIC WELL., ��r_" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION <br /> Industrial CATIONS. <br /> Cable Triol Dia.' of Well Excavation . <br /> Domestic/private Drilled Dia. of Well 'Casing <br /> Domestic/public Driven Gauge of 'Casing <br /> w" Irrigation _ Gravel Pack Depth of'Grout S�eal <br /> Type; <br /> ' � . <br /> Cathodic Protection ` Rotary of Grout <br /> J Dis�pds <br /> Other „, Il K.c tee. �y <br /> ��-�-- Other Information <br /> k__ �ophys�cal 5urfaCe S <br /> eal Inst�alled B rte: . <br /> R^` PUMP INSTALLATION: Contractor <br /> Type of Pum <br /> - p � � H.P. <br /> 44'A <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: StateWark Done <br /> , DES•TRUCTION OF WELL: Well -Diameter' ,.. <br /> Approximate bepth <br /> Desc ibe Material and Procedure <br /> a <br /> I hereby agree to comply wits all laws and regulations of the San Joaquin Local HealtI� D3 trI <br /> and the State"o.f California pertaining to or regulating wrell '�construction. Within FIFTEEN DRY ., <br /> after completion of, my work in a new well, I will furnish thd., San Joaquin Local Healt4 -District- E;. <br /> WELL. DRILLERS REPORT of the well and notify, them 'before putting the well in.,use. , The abc' I`' .. <br /> information is true to the b�st of my knowledge and belief. I WILL CALL FORA GROUT 'INSPECTION' <br /> PRIOR TO ,GROUTING'AND INA INSPECTION. <br /> ,,S I GNED <br /> TITLE _-(✓-i__le -t <br /> I (DRAW PLOT PLAN ON. REVERSE SIDE' u <br /> FOR DEPARTMENT USE ONLY � <br /> PHASE I ,A <br /> APPLICATION ACCEPTED BY <br /> DATE '-. + <br /> ' :ADBITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHASE III/FINAL INSPECTION <br /> INSPECT' ON.BY,' - - <br /> 6-�ir-Jy �, a _ ATE { INSPECTION BYDATE qI :la <br /> II:,._ .•._ 426 Rev. 1-74 f 77" �t <br />