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_ S?'TOAQUIN LOCAL HEALTH. DISTRICT ���,. +*f <br />'Or OFFICE USE: ; 1601- .Hazelton Ave., Stockton, Cali`, �� P ,� <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 raj -7 <br />(Complete In Triplicate) <br />?plication is hereby de to the San Joaquin Local Health District for a permit to construct <br />ad/or install the work:lherein described. This application is made in compliance with San Joaquin <br />aunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />OB ADDRESS/LOCATION 3 J J CENSUS TRACT <br />weer' s Name / fel. -�-. �. _ Phone 59-9- 3 C 3 <br />�- --- <br />.ddress M S- ��ri� City- <br />�i <br />.ontractor's Name S . License ��33L Phone �� -`73a` <br />,-YPE OF WORK (Check): <br />i, <br />DISTANCE TO NEAREST: <br />NEW WELL /;7' DEEPEN / / RECONDITION / / DESTRUCTION <br />PUMP. INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br />Other J / <br />;I <br />SEPTIC TANK X104 SEWER LINES PIT PRIVY ' <br />SEWAGE DISPOSAL FIELDy�`Tf CESSPOOL/SEEPAGE PIT OTHER <br />PROPERTY LINE - PRIVATE DOMESTIC WELL Y_*PUBLIC DOMESTIC WELL Ri <br />INTENDED USE „1 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />I Industrial ii Cable Tool. Dia. of Well Excavation <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 ;i. Rotary Type of Grout _ A) _ <br />Disposal I Other Other Information' <br />Geophysical Surface Seal Installed BY: 5 iiYdz' <br />PUMP :INSTALLATION: Contractor $I ' <br />Type of Pump H.P. <br />PUMP REPLACEMENT: State Work Done <br />ii r <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 we11•construction. Within FIFTEEN DAYS <br />after completion of my'work on a new well, I will furnish the 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 tolMthe best o£ my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ' <br />PRIOR TO GROUTING AN A FINAL INSPECTION. <br />SIGNED :' TITLE D"vnA'r- <br />7DRAW PLOT PLAN'ON REVERSE SIDE) <br />FOR D] <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />It%-SPECTION BY DATE <br />i; <br />ZTMENT USE ONLY <br />DATE '� 7 <br />P SE /FI INSPECTION <br />INSPECTION BY DATE /-.I;: 7J' <br />