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=� !j SAN JOAQUIN `LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ­'-(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT_ Permit No. Z./2]1d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby mad& 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 /> I JOB ADDRESS/LOCATION cam 111 /3 3 1510 151EYTdV K4 FSCAcon/CENSUS TRACT - <br /> Owner's Name - /9 C l Phone �-`�•S <br /> Address r3 ✓` rQl� rsC7qL0ti . (!?,qL f53 ZDCity <br /> Contractor's Name <br /> �-- L-icense # Phoney <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT 17 <br /> Other 1_7 `— <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> : = SEWAGE DISPOS -FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY <br /> LINE'-'� PRIVATE DOMES TIC:WELZ*Z <br /> PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial + <br /> 1 Cable Tool Dia..,-of.,aWe11 Excavation /6 <br /> Domestic/private Drilled Dia. kof Well Casing <br /> Domestic/public . Driven Gauge of Casing PZ_p T C <br /> Irrigation: Gravel Tack' Depth,of -_Grout Seal. <br /> Cathodic Protection Rotary -' % a - <br /> �_ y Type .of Groui•:� <br /> Disposal Other Other'Information T� <br /> Geophysical Surface Seal Installed By: RICLL. ,�J( <br /> PUMP INSTALLATION: <br /> Contra tor - <br /> Type of Pump �:, H:P <br /> f <br /> PUMP REPLACEMENT: . / / State Work Done <br /> _ r <br /> PUMP .REPAIR: / / State Work Done•,. <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 'I hereby agree to comply withal <br /> 1 laws and regulations of the Sats 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 Health District a <br /> WELL DRILLERS REPORT of .the well and notify them before potting the .well in use. The above <br /> information is true to the best of- my..knowledge and belief. I WILL CALL FOR A GROUT INON <br /> PRIOR TO GROUTING AND A FIN 41NSPECTION. REM <br /> SIGNED yzgief4TITLE o W/VJ_ <br /> 1 <br /> Y D ;OT PLAN ON REVERSE SIDE) <br /> PHASE i FOR DEPARTMENT USE ONLY M <br /> APPLICATION ACCEPTED BY _ i P DATE . <br /> ADDITIONAL COMMENTS: o �. <br /> t.•,, PHASE II GROUT- INSPECTION PHA I / INAL INSPECT ON <br /> INSPECTION BY: DATE INSPECTION BY DATE <br /> - - --- <br /> AE H 1426 Rev. 1-74 .-- ,- 3/76 2M <br />