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SAN JOAQUIN LOCAL HEALTH DISTRICT /d <br /> FO~ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 104-71. <br /> 0 —71 <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 herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/I A'zZ�IT' f I L l� �� !8 �`� l CENSUS TRACT <br /> Owner's Name Vd y h r` F bn Phone <br /> Address — (1 tI - --� � City -- <br /> r M <br /> Contractor's Name 1t�'11LA1 g Li nse one" <br /> a <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION DESTRUCTION DESTRUCTION /� <br /> PUMP INSTALLATION /j PUMP REPAIR / / PUMP REPLACEMENT /_ � <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC,TANK EWER LINES 7—­PIT PRIVY <br /> SEWAGE DISPOSAL �-I-ELD � CESSPOOL/SEEPAGE PI .f OTHER � <br /> PROPERTY LINE/y PRIVATE DOMESTIC WELL 7-7—PUBLIC DOMESTIC WELL <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION SPECIFICATIO S �\ <br /> Industrial Cable Tool. Dia. of Well Excavation � <br /> Domestic/private -�-- Drilled Dia. of Well Casing L b <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Nx,' Rotary Type of Grout � <br /> —Disposal-.,-" Other Other Information ! <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor ( ' <br /> Type of Pump I H.P. <br /> PUMP REPLACEMENT: / / State Work Done f <br /> i PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r--Approximate Depth C <br /> Describe Material and Procedure <br /> 1 hereby agree to comply with all laws and regulations ofSthe San Joaquin Local Health Distx t . - <br /> and the State of California pertaining to or regulating well construction. Within FIFTEENtDA <br /> after completion of my work on a new well, I will furnish thee San` Joaquin Local Health District '; <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 beliief: I WILL CALL FOR A GROUT INSPECTION <br /> i <br /> PRIOR TO GROUTING AND A FINAL INSPECT <br /> Ia <br /> SIGNED "'TITLE <br /> L ._ L ON REVERSE SIDE) <br /> OR BEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED $ DATE <br /> ADDITIONAL COMMENTS-:-- --�T_ � � <br /> PHASE II GROUT INSPECTION PHASE III/FIN INSPECTIO . <br /> INSPECTION BY DATE INSPECTION BY /_ 2DATE <br /> r] <br /> 2M <br />