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�- AN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: #' 1604 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ 1 -2 <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 /> bounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION OA K MAL E CENSUS TRACT _ - - <br /> Owner's Name f19, AILS - LAZANSEIV, Phone <br /> Address .2G 0 - 6 0 N( -14 1t 4 12 1 city\-ST&6�LP 011 <br /> Contractor's Name G 1 jAl 1 4 f> �, License # �(��'E Phone`114Z-1 YZ <br /> TYPE OF WORK (Check): NEW WELL /,V DEEPEN /7 RECONDITION /-7 DESTRUCTION /7 <br /> a PUMP INSTALLATION / / PUMP REPAIR /-7-PUMP REPLACEMENT ', f7 <br /> Other / / <br /> DISTANCE. TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial Cable Tool `-;Dia. of Well Excavation <br /> Domestic/private Drilled Dia._ of Well Casing <br /> Domestic/public Driven Gauge of Casing f' <br /> Irrigation Gravel Pack Depth of Grout Seal: ( _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information -- <br /> Geophysical r _�- Surface Seal Installed By: <br /> PUMP INSTALLATION: --Contractor <br /> TH.P. <br /> ype of Pump f <br /> PUMP REPLACEMENT: / / State Work Done <br /> war y — <br /> PUMP '.REPAIR: /7 State Work Done p <br /> ggS TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material-and- Procedure <br /> {'t 4 <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 Healtt ,District a <br /> i WELL DRILLERS REPORT of the well and notify them before putting the. well� in.use. The above <br /> ti- <br /> information is true to the-best-of my.knowledge and belief. I WILL CALL FOR A GROUV INSPECTION _ <br /> PRIOR TO GROUTING .AND Af7EINAL INSPECTION. <br /> r SIGNED 4TITLE 16 //� 1? <br /> -- <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> r <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHA II SEOUT INSPECTION PHASE III/FINAL INSPECTION <br /> ` INSPECTION BY DATE INSPECTION BY VAT.E <br /> i TE H 1426 Rev. I-74 r `�� � 1-74 2M <br />