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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. x-60& <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 VADDRESS/LOCATION 13 Rr W CENSUS TRACT <br />' Owner's Name Q f Phone _q �? f_ <br /> II <br /> Address Cit <br /> Contractor's Name .License # 3a - Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /% RECONDITION /_/ DESTRUCTION /_7 <br /> ,, fir PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /% y j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. SPIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1-67-0. CESSPOOL,/SEEPAGE-PIT �. OTHER'Z_ � <br /> PROPERTY LINE30PRIVATE DOMESTIC WELL �-_2 PUBLIC DOMESTIC WELL, <br /> INTENDED USE TYPE OF.WELL; , CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool' Dia. of Well Excavation ""-_- _ . <br /> Domestic/private Drilled :�17ia., of Well Casing f ! - <br /> Domestic/public Driven Gauge of Casing � _19j1ZC <br /> Irrigation Gravel Pack' Depth of Grotiit' Seal o <br /> Cathodic Protection >C Rotary - Type of Grout ! �p to <br /> Disposal Other i 'Other Information, . <br /> Geophysical Surface Seal :Installedm By: <br /> f PUMP INSTALLATION: Contractor—. --•----- �{ V� <br /> Type o.fY Pump . H p. , <br />� r <br /> Ir PUMP REPLACEMENT: J / State Work Done i <br /> PUMP .REPAIR: <br /> r / / State Work Done <br /> kDESmTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k 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 wellm'construction. Within FIFTEEN DA�S . <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND A FINAL INSPECTION. <br />` SIGNED - - _ ��_. �� _ . _ r TITLE _ f 0- <br /> Ze <br /> 1 , <br /> - -- ( PLOT PLAN. ON REVERSE SIDE) - ¢' <br /> - 4 <br /> OR <br /> DE ARTMENT <br /> USE ONLY <br />� PHASE I a <br /> iAPPLICATION ACCEPTED BY DATE Z7 <br /> PHASE <br /> r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE III/FINAL INSPECTION <br />' INSPECTION BY DTE INSPECTION BY ATE /� 4 <br /> 4-J3--)q 4 <br /> E H 1426 Rev. 1-74 i - p rfl7 - , 2M _: <br />