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t 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT S <br /> FORT!OFFICE USE: <br /> 1 U v°^ <br /> 1601 E. Hazelton Ave. , Stockton, Calif. K <br /> 4 <br /> Telephone: (209) 466-6781 <br /> II' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-7 '7f <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-I erein described. This application is made in compliance with San Joaquin { <br /> County Ordinance No. 1862 and the Rules and R do s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's 'Name Phone,���-- -�7� <br /> Addr e'ss _ Cit <br /> /ore• <br /> Contractor's Name I mS� License 45'010, hone <br /> TYPEOF WORK (Check) : NEW WELL /-A--DEEPEN /� RECONDITION / / DESTRUCTION <br /> I ; PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> j. <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK p .f SEWER LYNES PIT PRIVY �j ,I <br /> SEWAGE DISPOSAL FIELD ESSPOOL/SEEPAGE PIT OTHER C <br /> PRAPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL =:_- -�Cj <br /> INTENDED USE <br /> IlIndustrial <br /> I TXPE OF WELL CONSTRUCTION SPECIFICATIONS Cable Tool - -- -Dia.-of'-Well Ekcavation I / r <br /> stic/private I DrilledDia. of Well Casing <br /> :I�. Iic/public Driven Gauge of Casing <br /> IMi Irrigarrigation i Gravel Pack Depth of Grout S 1 x`92 <br /> !'Cathodic Protection otary Type of GroutIt <br /> .11 Disposal Other Other Information'' <br /> I1Geophysical Su ce Seal Installed B G'., <br /> PUMP_ ;INSTALLATION: Contractor *. <br /> _ Type of P pY.P. . <br /> . _ <br /> PUMP REPLACEMENT: :-r State Work Done <br /> PUMP ':REPAIR: State Work Done y <br /> DESTRUCTION OF WELL: Well Diameter ~''` ~ Approximate Depth <br /> - Describe Material and Procedure <br /> j- hereby agree to -comply'with all .laws and regulations'-of-the_San'Joaquin Local Health Distridt <br /> and the State of California pertaining to. q{r., regulatinlg we11�'construction. Within FIFTEEN DAYS <br /> after11completion of my work on a new_well-;-,I. will furnish the San Joaquin Local Health District a <br /> WIn <br /> LERS REPORT of the well�and;notify..them before put.ting ,the..well in use. The above <br /> in is true to t �' es 3 ,y'knowledge .and belief." 'I WILT; CALL FORA GROUT INSPECTION <br /> PG UTING ANDA pN a <br /> STITLE r .I <br /> - _ . <br /> i�' ' W PLOT PLAN ON REVERSE SIDE) <br /> T� <br /> FOR `DEPARTMENT USE ONLY >P <br /> APPLICATION ACCEPTED BY <br /> ;,. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION _ P E NAL INSPECTION <br /> INSPEII TION"BY - ,J lip. DATE 711 ') INSPECTION B DATE <br /> E H 1426 _,Rev. 1-74 _ ' 1177 2M <br />