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F 0 . #- <br /> %`" ;-- SAN JOAQUIN LOCAL HEALTH DISTRICT of <br /> FO F OFFICE USE: :" 1601 E. Hazelton Ave. , Stockton, Calif. I <br /> ' Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIONaOR PUMP PERMIT Permit No. <br /> G <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED Date Issued vl,-_1 7t <br /> (Complete In Triflicate), <br /> Application is hereby made to the San Joaquin Local He�aS th�DiA rict for a permit to Construct <br /> and/or install the work herein described. This application is.*made incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of. .the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 9 <br /> CENSUS TRACT ' <br /> Owner's Name <br /> dim <br /> iv-- Phone [Q <br /> Address L cl <br /> City <br /> f <br /> Contractor's Name <br /> F <br /> License �� t�Qchone� <br /> TYPE OF WORK (Check) : NEWS WELL <br /> ] / DEEPEN /_% RECONDITION /_/ ' DESTRUCTION /-7/ _ <br /> •Pgk? INSTALLATION /}�/ PUMP REPAIR / PUMP REPLACEMENT <br /> Other %.. / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 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 CONSTRUCTION SPECIFICATIONS <br /> 4lndustrialCable Tool Dia, of Well Excavation <br /> Domestic./private <br /> Drilled Dia. of Wei:1—Casing � _ <br /> Domestic/public ., : Driven Gauge of Casing <br /> Irrigation "; -- Grave1k,Pack Depth of Grout Seal <br /> Cathodic Prote"ctioii . ''Rotor <br /> —Disposal y Type of Grout <br /> Dis <br /> P 'Other Other Information <br /> Geophysical y Surface Seal Installed Ii <br /> PUMP �INSTA�LL�Z��ON- Coint_rac:or'"°" TJN� CQI&LA NJS <br /> - . <br /> Type of�,Pump:` '. H.P. _ <br /> PUMP REPLACEMENT: State StateWo. <br /> ' Work. Done <br /> PUMP :REPAIR: -" '` <br /> �-~r/4 / State iaark-Dorie � <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth <br /> 1. <br /> 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 pertainirig to "6r 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR-TO G OUTING AND A .FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> __..<. _,. (DRAW' PLOT-PLAN ON REVERSE'SIDE <br /> PHASEI AR' FOR DEPTMENT-USE-ONLY <br /> E <br /> APPLICATION ACCEPTED BY �, �. .d . - DATE <br /> ADDITIONAL COMMENTS: lzf <br /> " # <br /> PHASE II GROUT INSPECTION ` PHASE I FIN INSPECTION f <br /> INSPECTION BY DATE INSPECT? N -BY ATE <br /> E H 1426 -Rev. - 1-74. . <br />