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• ..--Y� <br /> QJOA SAN UIN LOCAL HEALTH DISTRICT Y - <br /> C, <br /> OFFICE USE: 1601 E: Hazelton Ave. , Stockton, Calif. <br /> 7 <br /> " Telephone: (204) 466-6781 w <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> zaug-/° <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8-13-7 <br /> (Complete In Triplicate) z <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 Joaquiul <br /> County Ordinance No. 1862 and the Rules and Regulations o the San Joaquin Ldcal.Health District. <br /> JOB ADDRESS/LOCATION 'L'v`Y3 tr s CENSUS TRACT' <br /> a' <br /> Owner's Name Phone <br /> . Address - - 7- City �`x`�'�--�� <br /> Contractor's Name � ' License # b=245-phone4g/27- <br /> TYPE.OF WORK (Check): NEW WELL L7 DEEPEN /-7. RECONDITION /7 DESTRUCTION r7 <br /> PUMP INSTALLATION L7 PUMP REPAIR / PUMP REPLACEMENT %T <br /> Other L/ <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 CONSTRUCT-ION_ SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout� � <br /> Disposal , Other Other Information <br /> Geophysical _ Surface Seal Installed BY: <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump W �L-d�h <br /> PUMP REPLACEMENT: L_1 State Work Done <br /> PUMP '.REPAIR: State Work Dane <br />} ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> r ` Describe Material and Procedure <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 well construction. '..Within FIFTEEN DAYS <br /> after completion of my work on 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-bestaf,��y awledge-an belief• I WIL17 CALL FOR A GROUT INSPECTION <br /> I PRIOR Z2,MUTING AND A FINAL PE ION <br /> SIGNED TITLE �6t' <br /> 7 6D PLOT PLAN DNREVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DAT_IXE U 3 <br /> A ADDITIONAL COMMENTS71: <br /> - PHASE II GROUT INSPECTION, PHAS& III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> `t E H 1426 Rev. 1--74 1-A Im <br />