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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � <br /> FOE OFFICE USE: '10�111601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _L__... <br /> _! � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (P� <br /> (Complete In Triplicate) 0(0 '-2-,-o�Q� <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 />.�.. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i <br /> Owner's Name T?`i Phoney4S_ - ' <br /> Address, �,S �.. �_ City 5 We <br /> IM <br /> Contractor's Name ,� License #AP ��,� Phone?j�.r�/3 <br />`TYPE OF WORK (Check) : AW WELL IA/ DEEPEN/ / RECONDITION / / DESTRUCTION /-7 .j <br /> 3 PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER e- <br /> PROPERTY LINES PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE., TYPE_QF -WELL_.-.---.—— CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool Dia, of Well Excavation /0 ", <br /> , <br /> ,7( Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven 4 Gauge of Casing _ rd - <br /> Irrigation ; Gravel Pack Depth of Grout Seal -s7•2 <br /> Cathodic Protection -_ X Rotary Type of Grout ,S'A&.�2 s(A-,z ?- <br /> Disposal Other Other Information ; <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ _ �, qF �6/✓S' <br /> _ " Type of Pump $' H.P. <br />'PUMP REPLACEMENT: /.I�/ State Work Done <br />,PUMP .REPAIR:, /.I�/ State Work Done <br /> i <br /> DES�TRU_CTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complyllwith 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 anew well,. I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use.. The above l <br /> information is true to tte best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 'I' TITLE ,6ty/vtr <br /> J� (DRAW PLOT PLAN' ON, REVERSE SIDE) , <br /> i FOR DEPARTMENT USE ONLY j <br />.PHASE I � .•< s�t`� � � <� <br /> APPLICATION ACCEPTED BY DATE �- g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ; _ ,.,;, PHASE III/FINAL INSPECTIOPIP <br />( INSPECTION BY J[ DATE INSPECTION {BY DATE / <br /> E H 1426 - .� 11,77 - 2M <br /> Rev. 1-74 r"'`. -- - - 1 <br />