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' R <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� -/�S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7� <br /> Ir (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 the San Joaquin Local Health District. <br /> B <br /> JOB ADDRESS/LOCATION , 1-712:' Ck U n1 CENSUS TRACT s <br /> � <br /> Owner's Name "IF DIV Phone <br /> Address J + Ih City <br /> f �rT t. ,� License Phoneyci�:�7 9 <br /> Contractor s Name W 2 L .f1V — - — .,�_. <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_>/ RECONDITION /� DESTRUCTION /� <br /> . PUMP.. INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ' <br /> Other :/ <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD""""`—CESSPOO-/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED# USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .►q <br /> Industrial Cable Tool Dia. -of Well Excavation 13 V` <br /> �' <br /> ,1-x.Domestic/private Drilled Dia.. of Well .Casing <br /> # Domestic/public Driven Gauge, 6f Casing IbO PV <br /> C. <br /> " Irrigation Gravel-Pack Depth 61 Grout Seal "`O <br /> k _ Ca-thodic Protection Rotary '.._ ., _._Type of- Grout +VsvN r 71- - - <br /> N Disposal Other r: Other Information $/-,95 a _0 .U17c►^ <br /> Geophysical Surface� Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Et,, . Type- . _ - - ,I T e of Pump - � H.P. <br /> ► s <br /> PUMP REPLACEMENT: / / State Work Donee <br /> PUMP :REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and yProcedure. <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAIS <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 pitting 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 /> `?RIOR TO GROUTING AND A FINAL INSPECTION. <br /> ►SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PLICATION ACCEPTED BY DATE -7S <br /> ZTIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSP CTION <br /> CTION BY DATE INSPECTION BY V _ DATE <br /> Q+� 1/77 ., 2M <br />