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SAN JOAQUIN LOCALHL'ALTri DISTRICT - <br /> Fd3F. OF'FICi' U5E: 1601 E. Hazelton 9-Fe . , Stockton, Calif. <br /> - <br /> Telephone : (209) 466--6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit. No. �/(13� <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. 1862 and the Rules-and Regulations of the San Joaquin Local Health District. i <br /> Y <br /> ' JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Ll ho�� kxe Aso <br /> _ Phone <br /> Address �ZYZZ2 . ALO_ -� +�, _ city ,�,Qr�� i <br /> N <br /> .'Contractor's Name `License #02 1 Phone <br /> ;TYPE OF WORK (Check) : NEW WELL DEEPEN`,/ / RECONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION, /. / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> '.-DISTANCE TO NEAREST: SEPTIC TANK 14V SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT , OTHER i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> • INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private i Drilled """ 'Dia, of Well Casing <br /> Domestic/public a: lGauge of Casing- <br /> Driven ( <br /> Irrigation Gravel 'Pack Depth-of Grout Seal <br /> i <br /> Cathodic Protection �_ Rotary , Type of Grout �,E �� J.f r <br /> Disposal ` Other Other Information e. <br /> Geophysical , Surface Seal Installed B <br /> PUMP INSTALLATION: . Contractor <br /> " <br /> Type of Pump Y H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ` f <br /> DESTRUCTION OF WELL: Well D`a:aTneter I Approximate Depth <br /> DescribO`Material and Procedure <br /> I hereby- agree to comply with all laws and .regulations of the San Joaquin Local Health Distract <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 Dis.t.rict' 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 INSPE,•CTION <br /> PRIOR TO GRO ING A ',,FINAI, INSPECTION. <br /> E SIGNED F TITLE <br /> 4 (DRAW PLOT PLAN.ON REVERSE SIDE) <br /> FOR DEPARTMENT .USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTIONPHA E III/FINAL INSPECTION, i <br /> INSPECTION B DATE i� r` `77_. INSPE ION BY - DATE <br /> 2M <br /> E H 1426 Rev. •`1-74 , <br /> 077 _ <br />