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r 'iYr' i <br /> ,L <br /> _ w SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOFn`-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone-: x.Q09) ' 466-6781 <br /> APPLICATION FORLkLL 'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �6 <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 herein described. This application is made in compliance with San Joaquin - <br /> County Ordinance No. 186. d.,.the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .S" f Ql� d CENSUS TRACT 0 9I(-3rd--3/' <br /> - �. i <br /> Owner's Name Phone <br /> Address City <br /> i <br /> i` <br /> G <br /> Contractor's Na cense # AzAahone <br /> p <br /> Ile <br /> TYPE OF WORK (Check) : NEW WELL '/V DEEPEN / / RECONDITION /771 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> O <br /> DISTANCE TO NEAREST: SEPTIC TANK wo-+ SEWER LINES PIT PRIVY r G <br /> SEWAGE DISPOSAL FIELD !S-y CESSPOOL/SEEPAGE PIT OTHER <br />' PROPERTY LINE 30�'PRIVA_TE ,DbMESTIt WELL' oot PUBLIC DOMESTIC WELL .: <br /> INTENDED USE TYPE U WELL 3 CONSTRUCTION SPECIFICATIONS ' <br /> _ <br /> Industrial <br /> -Cable Tool t.�Dia.. of 'Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauger of, Gading <br /> Irrigation Gravel Pack Depth of Grout: Seal d �� <br /> E Cathodic Protection Rotary Type of Grout . <br /> Disposal Other Other Informations <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State. Work Donee .r ... ` " <br /> PUMP .REPAIR: / / State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter `Approximate Depth 1� <br /> Describe Material and Procedure + f 4 <br /> I hereby agree to comply with all, laws and regulations of the Sans Joaquin Local Health District <br />` and the State of California pertaining to or regulating wel1''construction. Within FIFTEEN DAYS <br /> after comple 'on my work on. a new well, I1will furnish the San Joaquin Local Health District a <br /> WELL DRILL S REPOR of,Ithe,we_l and otify-them before: putting tkae*well' in u"s,e. `£The' above <br /> infarmati is ru _ the .be knowledge 'and�belie �I'WILL 'CALL FO 1 A. GROUT INSPECTION <br /> PRIOR TO OUT A F <br /> SIGNED TITLE- - ¢ <br /> (DRAW'PLOT, PLAN ON REVERSE SIDE) ° <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIOW ACCEPTED BY DATE //0 <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION P I/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1.2 <br /> ' 1177: ,2M- <br />