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r ..rte` „ ..�. .. .. ,;;,nk-•tirra..�r..� <br /> r �_ 10 7"k1 !f SAN JJAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OF1;I USE: 1601 E. 'Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name .14.6 . K..d Phone <br /> Address <br /> �-�3 � C �� b City <br /> Contractor's Name } ,� <br /> License # "Phone ),--7,67,( ! <br /> TYPE OF WORK (Check) : NEW WELL/ / ,D %EEPEN`/ RECONDITION J- / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR /)c/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled. Dia. ,of Well Casing 4� <br /> Domestic/public Driven Gauge of Casing - <br /> Irrigation I Gravel Pack Depth of Grout Seal N s <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done J <br />< PUMP .REPAIR: ILIState Work Done <br /> # _ 4 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedd're <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 we11 'construction. Within FIFTEEN DAYS <br /> after completion of my work oh 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-k "edge elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U ING AND A FINAL INSPECTIOSIGNED ITLE(DON REVERSE SIDE) i !:. <br /> k-40OR DEPARTMENT USE ONLY <br /> PHASE I �. <br /> APPLICATION ACCEPTED BYDATE / :-N <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IV/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / _ .e�7 <br /> E H 1426 Rev. 1--74 3/76 .2M <br />