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SAN JOAQUIN LOCAe-HEALTH DISTRICT <br /> FOVOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Permit No., jS 3l�(rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. <br /> (Complete In Triplicate) = <br /> Application is hereby madelto 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. 1'8621and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p '�. ,kem/_- ..:' CENSUS TRACT 06.3-290 X <br /> Owner's Name alm.'Vfy Phone 1731 e)X-93 <br /> i If I <br /> Address _ - -- , . _.,. ,---- city 1�Di <br /> - <br /> fa Y <br /> Contractorts Name �.;,i�f..���`�A7i5�CJ�A�.�`"� ,^ .�� ' —T".;� T.ice:ise # � Phone (� <br /> TYPE OF WORK. (Check):+ NEW WELL /; DEEPEN /_7 RECONDITION'. L7, <br /> .7 DESTRUCTION <br /> PUMP INSTALLATION / J PUMP' REPAIR PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC T SE S PIT PRIVYI <br /> ` SEWAGE DIS AL FIEL `` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA STIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �Industrial " ` g-- - ---Cable-Tool_,_Dia..,Dia. of Well Excavation 4:L <br /> �bomest_ic/,pr.ivate Drilled o Dia. of WellCasing .,.. <br /> sme tic/Public -" '' -D i.ven �=-Gaugeaof=Casiag,. <br /> Irrigation, N Gravel Pack Depth of Grout Seal <br /> ► Cathodic Protection L,- Rotary Type of Grout <br /> Disposal Otheir Other Information <br /> Geophysical 'Surface Seal Installed BX: , ,;LAj5) j <br /> PUMP INSTALLATION: 'Contractor <br /> Type of Pump Sy$ R.P. <br /> a <br /> PUMP .REPLACEMENT: ; / / State Work Done <br /> PUMP--REPAIR-s- — / Stiate Work Done <br /> 4ES'TRUCTION OF WELL: ,Well Diameter Approximate Depth <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 pertaining to or regulating.•well construction. Within FIFTEEN DAYS <br /> after completion of my''work on a 6ew '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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED'. TITLE ,E'4LFj3 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTPD BY TT^ - - DATE ; - <br /> -,ADDITIONAL'C'd16=s t / <br /> 4 P.HASE'II. GROUT.- INSPECTION PHASE III FINAL INSPECTION <br /> -INSPECTIONBY. .DATE "' INSPECTION BY DATE /.;X ' <br /> h �; 'E H. 1426.' Rev.``1-74 1-74 2-H <br />