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- K�r <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT IV A' t 4� <br /> F OFiCT1S'E': 1601 E. Hazelton Ave.', Stockton, Calif. t elf.��r ~ <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTI N OR PUMP PERMI Permit No.2 - f��7a) <br /> �G��f u <br /> Gl. Snc�ve y THIS'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date slued L`- -)7 <br /> l <br /> F � f : (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. 1,862 %nd the ORules and Re Mations of the San Joaquin Local Health District. <br /> a <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's NamaL I?-7 4 57e �� _ - f qL_? tPhone <br /> Address S-2? City <br /> t Contractor's Name License # �V/,MPhone ' y <br /> TYPE OF WORK-(Check) : -NEW WELL �/ DEEPEN / / RECONDITION. /_7 DESTRUCTION /_7 <br /> PUMP INSATION PUMP REPAIRP <br /> I I UMP REPLACEMENT /_7 <br />` Other <br /> DISTANCE TO NEAREST: {,SEPTIC TANK I. -SEWER LINES } PIT PRIVY ' <br /> rSEWAJdE biSPOSAL-FIELl,_--�—�, C SSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ""-`` CONSTRUCTION SPECIFICATIONS <br /> Industrial A <br /> Cable Tool Dia, of Well Excavation , <br /> &--�Domestic <br /> /Private .;, 4-`Drilled Dia, of Well Casing O <br /> Domestic/public Driven <br /> Gauge of Casing;_ �j <br /> Irrigation ' Gravel Pack Depth of Grout, Sea1 <br /> Cathodic Protection c.---Rotary Type of Grout <br /> ' Disposal i. Other Other Information. <br /> Geophysical y Surface Seal Installed B <br /> b <br /> PUMP INSTALLATION: Contractor ` _ } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . ; <br /> State Work Done <br /> PUMP .REPAIR: State,.Work Done --- <br /> DESTRUCTION OF WELL: Well Diameter j Approximate Depth <br /> Describe Rdterial and Proce ure <br /> I hereby agree to comply with all laws and regulations-of the San Joaquin Local Health District F <br /> and the State of California pertaining to or regulating weZ `canstruction. Within FIFTEEN DAYS j <br /> after completion of. my work on a new well, I will furnish thefSan Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A 'FINAL I S I <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS4 <br /> e;�JI/FIN4L INSPECTION ' <br /> INSPECTION BY DATE ' ?J 7 -7 7 INSPECTION BY DATE <br /> - ��� I ,�� � rte,..., <br /> ,�E H 1426 Rev. I_-.7�+,:..r �-J.,- l�j'� " <br />