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e <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT a y <br /> FOR FFICE USE: �� 1601 E. Hazelton Ave. , ,Stockton, Calii. -- / <br /> 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.-2 7d <br /> u (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 Joaquit <br /> County.Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ^/(/, (�(/, (d�'il1F (JITAL!/A/t'� f2,0 ��✓U SP�EC&4ESENSUS TRACT <br /> i d <br /> r. Owner's NamG�i� Bl,�lJC / Phone <br /> f: Address - & ZLE E. UER,Gi'AS _ City ' A9AA1Wh—, <br /> ► Contractor's Name C, WA47Z2 c)Rl41_I116 rd. License # Phone <br /> [ TYPE OF WORK (Check) : !!NEW WELL AL� DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> O PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / „* <br /> p <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 3, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2 `0 <br /> Domestic/private" Drilled Dia. of Well Casing " _�, <br /> Domestic/public ! Driven Gauge of Casing X4 WAa <br /> - Irrigation Gravel Pack Depth of Grout Seal 142 _ <br /> Cathodic Protection �_ �[ _ Rotary Type of Grout <br /> Disposal ' Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> S <br /> ' PUMP INSTALLATION: i° Contractor <br /> f <br /> IType of Pump H.P. , <br /> PUMP REPLACEMENT: I / / State Work Done <br /> PUMP .REPAIR: i� /_,; / State Work Done <br /> �DE5TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Material and Procedure <br /> i <br /> rI 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 mylwork on a new well, I will furnish the San Joaquin Local Health District <br /> :. WELL DRILLERS REPORT of the well and notify them before putting the..wel1 in use. The above <br /> information is true tolthe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ,PRIOR TO GRO T NG AND A FINAL INSPECTION. <br /> SIGNED TITLE 4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> '.PHASE I <br /> ;APPLICATION ACCEPTED BY DATE I� <br /> ==ADDITIONAL COMMENTS: l <br /> PHA5E II 'GROUT INSECPHAS III/F INSPECT N <br /> INSPECTION BY DATE INSPECTION BY DATE ✓- 76 . <br /> �- 3v-7B . <br /> j 11 77 2ND <br /> E H 1426 Rev. 1-74 <br />