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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4(�- OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> VX <br /> Tele hone :p {209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 i f A,J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 6 <br /> (Complete In Triplicate) <br /> I;. Application is Aereby 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 ADDRESS/LOCATION e / D n <br /> r. ............ 1U CENSUS TRACT <br /> Owner's Name Lq <br /> r d Phone 13I - . <br /> z;Address` 7 /, � �� <br /> % �-CJ City <br /> Contractor's Name L, WFI-L <br /> License #7 O Z Phone <br /> VLZ- Z <br /> TYPE OF WORK (Check) : NEW WELL / _DEEPEN ./ h. RECONDITION./ -/,__DESTRUCTION_./�. <br /> PUMP INST LATION / / PUMP REPAIR <br /> Other / / / / PUMP REPLACEMENT /-7 i <br /> DISTANCE TO NEAREST: SEPTIC-TANK 136 SEWER LINES ad�f'PIT PRIVY ~ <br /> SEE AGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE fTYPE-OF-WELI.— CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of Well Excavation , <br /> Domestic/.private Drilled �. <br /> Dia. of We11 Casing <br /> _ Domestic/public 1 Driven —Gauge of Casing - (y 1 <br /> Irrigation Gravel Pack+ Depth of Grout Seal. <br /> Cathodic Protection .�Ro.tary' i Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical ... Y_ ��, _. <br /> �� Surf ace `Seal Installed B : <br /> PUMP INSTALLATION; } <br /> Contractor '' <br /> Type`ofaPump - �. r <br /> H.P. . <br /> PUMP REPLACEMENT; / / State Work Done <br /> PUMP .REPAIR: /-7 State Work Done <br /> � M <br />)ES-TRUCTION OF WELL: Well Diameter <br /> Describe` Material and Procedure Approximate Depth " <br /> L 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 /> ifter completion of my work onia new well, I will furnish the San Joaquin Local Health ,District a <br /> BELL DRILLERS REPORT of the well and notify them before putting the-well in use. The above <br /> LnformatioiVis true to the best_ of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RI IR TO OUTING AND A FI I P • ION. <br /> i IGNED <br /> r TITLE <br /> ---(DRAW_PLOT-PLAN_ON_REVERSE_S.ID.E.)`,,,,,,__ <br />,RASE I # FOR' DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROAT INSPECTIO PHASE TII/FINAL INSPECTION <br /> NSPECTION BY f� DATE G d INSPECTION BY DATE 6 <br /> E .H,1426 Rev. 1-74 rrz . 1 J77 aar <br />