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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFTCE USE: 1601 E. Hazelton.Ave. ;,:Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION "OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM <br /> DATE ISSUED Date Issued <br /> , �✓ (Complete In,.Triplicate) 221 ogcs �3 <br /> Application is hereby made `to=•the San Joaquin' ocel' Health District for a permit to czatruct <br /> and/or install-the-York herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No 1862 and the Rules and egulations of the San Joaquin Local Health District. <br /> W CRN. I Me <br /> NRIX .� DOSf-LCL"'T—, <br /> JOB ADDRESS/LOCA ON .f, a E. FS C A CENSUS TRACT <br />� Owner Q s Name -'- A&01: <br /> if L r Phone <br /> Address'- City <br /> Contractor's Name � _ Licensed Phone <br /> t <br /> TYPE OF WORK (Check): NEW WELL -/T DEEPEN/-' RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /1 PUMP REPLACEMENT f-7 <br /> Otherp// .. <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES { <br /> PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTICWELL PUBLIC DOMESTIC WELL _ <br /> INTENDED USE STYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool "` ' Dia. sof Well Excavation <br /> Domestic/private- y --4---Dr11led- - �--..w-..-Dia:-of Well Casing <br /> Domestic/public I Driven 1 11 Gauge of Casing P" <br /> Irrigation Gravel Pack` ` w . Depth of Grout Seal <br /> Cathodic Protection # Rotary 's;� A 3 -Type of Grout—`— r <br /> Disposal Other 1 Other Information 1 + <br /> Geophysical �"�. W <br /> -Y +a Surface Seal Installed,By: . I <br /> PUMP INSTALLATION: -, Contractor <br /> j Type of Pump S.P'. <br /> PUMP REPLA ` <br /> CEMENT:.` ; ,�� / ,,/ti, State. Work Dane <br /> PUMP :REPAIR: ` ` i <br /> State Work Done ADS p ik <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <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 constructWithin4FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS -REPORT-of-the well and notify them before puttingthe..well in-use. The above <br /> information is-true to. the.best of my .knowledge and belief. I WILL CALL F0 -A GROUT INSPECTION <br /> PRIOR TOG TING AN A FINAL 1 INSPECTION. <br /> : <br /> SIGNED I <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FO ARTMENT USE ONLY <br /> AITACCEPT v Ar LI 1%f 0 7`� DATE <br /> ADDDDITIONALIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHA&VIT SOT -INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE _ <br /> � ,E H 1426 Rev. 1-74 <br /> k <br />