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11601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFOFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> of r Telephone: (209) 466-6781 <br /> APPLXCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �p <br /> VV <br /> TIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /16 a' F p/t' iqE Y/?� �' s &I CENSUS TRACT <br /> `_ <br /> er's Name �� "' 'I� Phone �Gfj'� <br /> �ddress Q '��dl/6 F City <br /> n .a <br /> ..ontractor°s Name ense Phone 1! <br /> YPE OF WORK (Check) . NEW WELL /�EEPEN ' 7. RECONDITION f-1 DESTRUCTION /-7 <br /> PUMPJINSTALLATION 44 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY S <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 /> Industrial '"^ Cable Tool Dia. of Well Excavation <br /> /�' Domestic/private !�' '" Drilled Dia. of Well Casing <br /> FHf <br /> Domestic/public_. Driven Gauge of Casing 12 <br /> Irrigation / ..-, Gravel Pack Depth of Grout Sea <br /> Cath$dic Protectionnary Type of Grout <br /> Disposal ° I ".Other? Other Information e. r <br /> Geophysical w � _ Surface Seal Installed By; <br /> UMP INSTALLATION: Contractor <br /> Type of Pump �sr H.P. S PT_ <br /> — —T <br /> RUMP REPLACEMENT: State,Work Done <br /> PUMP .REPAIR: 4 / .% State Work Done <br /> " ' Approximate <br /> ESTRUCTION OF WELL. ;We11 Diameter �"7 APP Depth <br /> ( :"+`;Describe Material and Procedure <br /> hereby agree ;to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my woikllon a new well, I will furnish the San Joaquin Local Health District a <br /> hLL DRILLERS REPORT 6f 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 GROU_T_I_NSPECTIO <br /> ?RIOR TO jr.ROWIbWjAND A Ff, Aa INSPECT <br /> 'SIGNED _r TITLE <br /> D' # (DRAW PLOT PLAN ON REVERSE SIDE) <br /> p� /1 FOR ARTMENT USE ONLY pn <br /> PHASE I 9 ) I ' ( �O <br /> 'APPLICATION ACCEPTED BY .{. �.J DATE � /P <br /> ADDITIONAL COMMENTS: 0 <br /> PHASE II—GROUT i#INSPECTION PHASE III/FINAL INSPECTION <br /> 'INSPECTION BY -'DATE ' ' a = INSP.ECTION,'BY ' P <br /> DATE ; <br /> 2M <br /> E H 1426 Rev. • 1-74 b/77• - <br />