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USE= <br /> SAN JOAQUIN LOCAL ILEAL l h t <br /> F—F-6: OFFICE USE:= 1601 E. Hazelton Ave. , Stockton, Calit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -16 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued v 7 <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 Eerein described. This application is made in compliance with San Joaqu: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION M-+' a 12lrpetmNo- moo raver a CENSUS TRACT <br /> Owner's Name Kenneth/Lane Phone <br /> Address _ 203'30 E. Hwy, 12 City f`taamEitG <br /> Contractor's Name yrnjP- RT N^ PTTMP r TRRTrn=:ON- TNS`- _ License f -Angn-Al Phone _723&55" <br /> TYPE OF WORK (Check): NEW WELL L-7 DEEPEN /? RECONDITION /7 DESTRUCTION L <br /> PUMP INSTALLATION L� PUMP REPAIR / PlJlP REPLACEMENT r7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMFSTIC WELL .—. PUBLIC S I <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 /> 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 ^ Sorfdce Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done airs to IRHP Pomona - <br /> DESTRUCTION OF WELL: Well Diameter - - - Approximate Depth <br /> r; 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ", informationue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> :PRIOR TO is D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> ry <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ppp ICATION ACCEPTED BY 9100DATE 9 � 2 <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II OUT INSPEC'iION DATE y <br /> INSPECTION BY DATE INSPECTION BY > <br /> 1/77 2M <br /> E H 1426 Rev. 1-74 <br />