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SAN .JAAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1501 E. HazeltozI Ave. , Stockton, Calif. <br /> ' Telephone: (209) 465--6781 � � � i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �o <br /> -41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued --'12-611-2y/` <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 <br /> the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ � � � / �GGi GL j� �C� CENSUS TRACT I <br /> Owner's Name —... f_ _ /7'd •"�L+°S' Phone <br /> Address [174 __.• `,.,,_.__._.,_ City 114C 1Wf^ <br /> l <br /> / f i <br /> Contractor's Name _ C.7"l-`as C/- ( ,��Gl y License ��,� Phone <br /> A <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/_/ RECONDITION /-7 DESTRUCTION /-7 <br /> 1 PUMP INSTALLATION ./ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> 0 they <br /> DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY �V <br /> S'EWNGE-DISPOSAL F3ELD -- 'T —'CESSPOOL/S-EEPAGE-PIT —OTHER' <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation rf � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 04 J✓1 � ,� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> a <br /> PUMPfREPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 GROUTI4W,,4EDAFI IN N. - <br /> SIGNED' TITLE it <br /> DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r DATE i <br /> 147 2M � <br />