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+ SAN JQAQUINIOCAL.HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. HazeltonAve: ,`-Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PLW .P:ERMIT7� `Permit 'N6 -.307 W <br /> THIS PERMIT EXPIRES" 1 YEAR FROM;DATEISSUED Date `Issued ° -!1'7 <br /> _ �, tCo:nplete In Tr�p;�icate) > ...., . . , • . . .�`, <br /> Application is hereby made to the San Joaquin Local. Health Dietrict; ar. a,permit t'o"construct <br /> and/or install the work, herein described:' 'This"application,.,is made in:..compliatcte with-.San Joaquin <br /> County Ordinance No. 1862 and h Rul' s -and Regaations�rf t e S n Jo Lac' 1 -H . Ith `District. <br /> JOB ADDRESS/LOCATION :CENSUS TRACTOwner s Name' <br /> Phone. . _ � .—g ef'o <br /> Address. - -- ': <br /> City <br /> Contractor's Name - . -..,-License # o7 Phone. �3� jj-7v <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION /_� DESTRUCTION /-j.. <br /> PUMP INSTALLATION /�'`,PUMP.?REPAIR /� � PUMP <br /> other REPLACEMENT <br /> ' J J <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES' PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELDf.�CESSPOOL,rSEEPAGE PiT -OTHER V <br /> PROPERTY LINE--.- 'PRIVATE-DOMESTIC WELL PUBLIC- DOMESTIC WELL <br /> I INTENDED USE , TYPE OF .WELL CONSTRUCTION SPECIFICATIONS <br /> Indus trial <br /> -- L Cable Tool Dia. .,of -Well Excavation <br /> Do stir/priv a Drilled` h `Dia. of Well- Casing 0 • <br /> Irr�gatians tic ubli .rDriveri Gauge ofCasing <br /> `Gravel=�aCttepth.o£ Grout Seal t �- <br /> P . <br /> rt �� . <br /> f Cathodic-•Protection Rotary' . Type of .Grout <br /> Disposal Other Other Information <br /> ' Geophysical � ' <br /> E Surface Seal Installed By: = <br /> PUMP INSTALLATION: Contractor = <br /> Type of Pump - — H.P. <br /> PUMP, REPLACEMENT: . / / State Work Done <br /> YPUNIP-LtEPAiitR- — <br /> ES1RUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> E <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and -tlie State of California pertaining to or regulating well construction.. Within- FIFTEEN DAYS <br /> afte=. completion of my,work on a new well, I will. furuish 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 l=owledge and belief. I WILL -CALL.FOR A GROUT INSPECTION <br /> PRIOR. TO G OUTING AND A FINAL INSPECTION. # <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION`ACCEPTEDBY DATE 7 7 <br /> ADDITIONAL COMMENTS:'A <br /> PHASE'-II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY . DATE 4 <br /> INSPECTION BY­ <br /> DATE <br /> E S 1426 Rev. 1-74 <br /> „. 1-74 2M <br />