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f 1N JOAQUIN LOCAL HEALTH DISTRI, ' <br /> FOT,OFFICE '.USE: 1602.E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:: <br /> • p (209) 46.6-6781 <br /> IM APPLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT Permit No. 22:21-19'&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE Deit <br /> ed / 7 <br /> (Complete In Triplicate) <br /> App cationl�is hereby made to the San Joaquin Local Elealth District construct <br /> and/or instull, the work herein described. This application is made in compliance with San Joaquin <br /> County Ordi�N ace No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> .FOB ADDRESS/LOCATION l CENSUS TRACT <br /> Owner's Name Phone <br /> IM <br /> Address F o a CityI�''� �T �•z <br /> k Contractor's� Name License IZmv Phone9ZIF F7/J <br /> , TYPE OF WORK (Check): NEW WELL b_<7 DEEPEN ' _7 RECONDITION f-7 DESTRUCTION /7 <br /> 'i PUMP INSTALLATION /T PUMP REPAIR '/� PUMP REPLACEMENT /7 <br /> ' Other <br /> DISTANCE TO -NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <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 /> F 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 __X Rotary Type of Groutr---- <br /> Disposal Other Other Information <br /> Geophy�{cal Surface Seal Installed 'B : C�czr <br /> k <br /> . PUMF INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR:, /_7 State Work Done <br /> �OS.TRUCTION 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 RE�� <br /> and notify them before putting the..well. in use.... The `above <br /> information isof kno edge,, and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTI SPE IO , <br /> 'SIGNED F TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY <br /> {PHASE I :� Q <br /> APPLICATION ACCEPTED BY DATE 7�' <br /> 'ADDITIONAL COMMENTS <br /> jPHASE II GROUT INSPECTION PHASE IIIF NAL INSPECTION <br /> INSPECTION BX DATE /-2 X77 INSPECTION BY DATE <br /> E H 1426 '1 Rev. 1•-74 _ 1,/?e. 9M <br />