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} SAN JOAQUIN LOCAL HEALTH DISTRICT {�� <br /> F3OFrli5r ` <br /> ICE"USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> I Telephone: (209) 466--67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> mit No. �f$� <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Bate Issued <br /> Application is � (Complete In Triplicate) `-•`---��- <br /> y 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 Joaqui <br /> S n L al Health District. <br /> JOB ADDRESS/LOCATION ,� �► a / LtI S 7g � •� r� ! <br /> CENSUS <br /> Owner's Names h��^t 1.7-3 <br /> Phone 7 31 S <br /> Address -- <br /> X City,- ,o <br /> Contractor's Name Ile, <br /> 1111611, <br /> 5 <br /> G.. , <br /> lLicense � sfi'd Phone !7as- <br /> TYPE OF WORK (Check)`:°` NEWELL /kf DEEPEN /_/ RECONDITION /_/ DESTRUCTION-./_7 <br /> PUMP INSTALLATION / PUMP REPAIR <br /> Other / / / / PUMP REPLACEMENT ,,,/� <br /> DISTANCE TO``NEAREST: SEPTIC TANK _ <br /> _ SEI,TER LINES M gip^R -4p. <br /> f SEWAGE DISPOSAL FIELD a CESSPOOL/SEEPAGE PIT � OTHER <br /> PROPERTY ! -! ` ' <br /> t INTENIIED USE L1NE PRIVATE DOMESTIC WELL i�. PUB <br /> E TYrE OF WELD - C DOMESTIC"WELL <br /> ..¢ Indiistxial <br /> t CONSTRUCTION%SPECIFICATIONS <br /> Cable Tool Dia, of Well Ekcavation <br /> Domestic/private - Drilled w <br /> Domestic -- :------t�Dia, of Well Casing <br /> /public ! Driven Gauge of Casin _ <br /> Irrigation _ Gravel. Pack, Depth oGrout gSeal <br /> Cathodic Protection - Rotary <br /> Disposal Type of Grout <br /> Other o <br /> Other Infrmat-ibn <br /> Geophysical � <br /> ac'aAS.e,al_Ins_tal3e.d. B17 <br /> f` J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP .REPAIR: ' z <br /> / State Work Done <br /> DESTRUCTION OF WELL. Well. Diameter <br /> r <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <br /> and the State of California pertaining to or regulating well 'constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a t <br /> 4ELL DRILLERS REPORT of the well and notify them before Putting . the. well in use. The above <br /> Lnformation is true to the best of m knowledge and belief, <br />'RIOR TO GROUTING AND A FINAL SPE CT ION. g I WILL CALL FOR A GROUT INSPECTION � <br /> SIGNED z i <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />'RASE I FOR DEPARTMENT USE ONLY <br />�.PPLICATION ACCEPTED BY <br /> r T <br />,DDITIONAL COMMENTS: DATE //-/,o <br /> NSPECT <br /> PHASE- 1-I GROUT INSPECT- N Ll -I/FIN INSPECTION <br /> N BY DATE 7 INSPECTION BY8i <br /> p BATE <br /> E H 1426 Rev. . 1-74 <br />