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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF.OFFIGE USE: ' - <br /> �1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 9 40 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No� <br /> DS <br />° THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> Date Issued <br /> Applicatioiplicate <br /> n is hereby made to the San {Joaquin eLocal In rHealth District fora 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 ADDRESS/LOCATION 25, r / <br /> / cYi2� -x*-CENSUS TRACT <br /> # )2a <br /> Owner's Name ! �aw ^� d. i <br /> k Phone _ s a <br /> Address . f't // , <br /> ~ City _ c r •i<�,�f <br /> Contractor's Name �'— <br /> t <br /> License ��f� r� Phone 3 - <br />' TYPE OF. WORK (Check) : NEW WELL DEEPEN/% RECONDITION /7 DESTRUCTION /7 a <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK "" <br /> W SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSALFI9LD CESSPOOL/SEEPAGE PTT <br /> -PROPERTY LINE LINE PRIVATE. DOMES-T-IC WELL - PUBLIC DQMESTIOTHE L <br /> INTENDED USE TYPE_ OF WELL —�� <br /> Industrial " "' �.r _ CONSTRUCTION SPECIFICATIONS <br /> Cable 'Tool ` Dia, of Well Excavation / « <br /> Dauiestic/private 1. Drilled Dia._of Well,�Casin lDomesti°c""ub11c.. �, �.. ._. _. - <br /> _ Driven- -._:.�.=� _ - - ��--�----- .g�--- <br /> Irrigation Gauge of Casing r i <br /> I Gravel Pack Depth of Grout Seal <br /> Cath6aic Protect__ion } Rotary Type of Grout V <br /> Disposal > Other Other Information <br /> Geophysical F <br /> � ? ' � ---' . <br /> ..F Surface Seal Installed By. <br /> PUMP INSTALLATION:, Contractor <br /> v <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: F <br /> /_7 State Work' Done <br /> PUMP :REPAIR: <br /> State Work Done � <br /> DES•TRETCTTON pF WELL: Well Diameter { <br /> Describe Material and Procedure Approximate Depth <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 onla 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 GROUTINSPECTION <br />?RIOR TO GROU IN AND A F INSPECT TON. <br /> SIGNED <br /> TITLE <br /> IV Ir <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> 4PPLICATION ACCEPTED BY DATE 7 <br /> 4DDITIONAL COMMENTS: F <br /> PHASE IT GROUT INSPECTION P III IN INSPECTION <br /> - <br /> INSPECTION BY DATE INSPECTION BY' DATE <br /> A <br /> E H 1426 Rev. I-74 �� 1-77 <br />