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a <br /> 1 <br /> SAN JOAQUIN LOCAL HEALTH,DISTRICT i <br /> ' FO1��OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, -So <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <br /> (Complete In Triplicate) �2_j S� -42^ <br /> Application is hereby made to the San Joaquin Local Health District for a pert to construct <br /> and/or-install the work herein described. This application is made in compliance with San Joagxdb <br /> County Ordinance. No. ,1862 an& the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,q C �/ CENSUS TRACT <br /> Owner's�hName a r r e;aj ) Phone z <br /> Address rQ1- { City C <br /> Contractor's Name" ens,,_- Phone � <br /> TYPE OF WORRY?(Check) : NEW WELL /�� DEEPENRECONDITION /�, DESTRUCTION /7 <br /> PUMP`INSTALLATION -/-7—PUMP REPAIR /_ , Pump,REPLACEMENT 0 <br /> Other / / : -C-A- <br /> DISTANCE TO NEAREST: SEPTIC TANK ;;SEWER LINES PIT, PRIVY <br /> SEWAGE DISPOSAL FIELD C_ESSP00L;/_.SEEPAGE PITT „� OTHER i <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL'^ PUBLICIDOMESTIC WELL <br /> INTENDED USE TYPE OF WELL-w CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing- ' _-r' <br /> Domestic/public i f Driven Gauge of Casing <br /> .Irrigation iGravel Pack Depth of Grout Seal ° <br /> Cathodic Protection Rotary - Type-of Grout <br /> Disposal 9 Other Other Information <br /> Geophysical Surface Seal Installed By: 11}} <br /> 'PUMP INSTALLATION: Contractor <br /> Type of Pump �" H.P. <br /> PUMP REPLACEMENT: / / State Work Doneaw <br /> PUMP,:REPAIR: /-7 State Work Done <br /> �r <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth DU <br /> Describe Material and Procedure <br />' I hereby agree-to comply with all Yaws and regulations 'of the San Joaquin;Local;.Health District <br /> and the State of California pertaining to or regulating well construction Within Within FIFTEEN DAYS <br /> after completion of my„ work.on a new well, I will furnish the San Joaquin jIioeii­liealth District a <br /> WELL DRILLERS REPORT of the well and notify them before puttin,g.. the .well iri.uae. The above <br /> f information is true to the-best of- my 'knowledge and be ief. I WILL CALL �,OR' "A tROUT INSPECTION <br /> PRIOR TO GROUTING A F NAL N PECTION <br /> SIGNED TITLE � . <br /> D LOT P REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 'GROUT Z S CTO , _ PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 2 -7 <br /> �, E $ 1426 Rev: ]. -7 4 CAvI W`A , YlP.9 29 A190 <br /> 94 <br />