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y y�%�� w g p � �. -tins� � _ ='��•a.Y+i+a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE GFFICLF USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> AM" v <br />' ► " THIS PERMIT'EXPIRES 1 Y FROM DATE ISSUED 'Date Issued ��1'�I <br /> (Completej'In Tr'plicatc) : <br /> Application-is hereby made to 'the San Joaquin Local ealth 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 Ordinanc No:". 1862 and the Rules and Regulati_on"s o h San Joaquin-Local Health District, <br /> S"}N Y+4�7 AcG Pv x3 rn . C�3- f50 <br /> t JOB ADDRESS/LOCATION zoCENSUS TRACT <br /> . . . <br /> Owner's yName- <br /> ire <br />` T GSS Phones C? — <br /> I <br />€ Address. <br /> City'' <br />~Contractor's Name 'v <br /> License #. / 7&j Phone <br /> TYPE OF WORK (Check) : ._NEW WELL/ / DEEPEN--/-/ RECONDITION /? DESTRUCTION /_7 ! <br /> PUMP INSTALLATION *REPAIR /X/2PUMP REPLACEMENT /_7 f <br /> ` Other- / / - - — _, <br /> f - <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY C9 <br /> „.. 4- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> .PROPERTY LINE -- PRIVATE' DOMESTIC ,WELL ' PUBLIC DOMESTIC WELL 0 <br /> INTENDED USE x :TYPE OF WELL <br /> t CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Ga_ <br /> ble ,Tool Dia. of Well Excavation ' <br /> Domestic/private Drilled. Dia, of Well Casing <br /> Domestti,c/public , <br /> -, Driven Gauge of Casing <br /> _r�XIrrigation - - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout #, <br /> Disposal Other -y Other Information <br /> Geophysical- _ ' Surface Seal Installed By:_ <br /> PUMP-INSTALLATION: t Contractor <br /> F Type of `Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / _Sta-te Work Done <br /> l <br /> PUMP '.REPAIR:: r--- <br /> /I^�/..,,.State Work Done..' <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth i <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 Califorziia 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 knowled aTM elief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL N," <br /> SIGNED ITLE <br /> RA LO PLAN ON ERSE SIDE) # <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' <br /> APPLICATION ACCEPTED.. BY DATE <br /> ADDITIONAL COMMENTS: { <br /> PHASE -II GROUT INSPECTION PHAOL I'II NAL INSPECTION '- I <br /> INSPECTION BY INSPECTION BY DATE h <br /> E H 1426 Rev. 1-74 I177: 2M <br />