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r f <br /> SAN JOAQLPTN; LOCAL„HEALTH DISTRICT <br /> FOR,OFFICE USE: A 1601 E. Hazelton Ave. , .Stockton, Calif: f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. OD <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is tereby 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 Ord narice .No. ;1862 and the Rules and Regulations of the San Joaquin Local Health District. l <br /> JOB ADDRESS/LOCATION �_ GJ .( ,��� _Lfv E _ CENSUS TRACT <br /> Owner's Name Phone� ,�L.� n r,( �F� <br /> Address . city ✓.eA.Lai <br /> Contractor's Name F I License �+ + /L[�! Phone y <br /> l <br /> i <br /> TYPE OF WORK (Check) NEW WELL / J DEEPEN J.j RECONDITION DESTRUCTION /-7 i <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES fDU-r . PIT PRIVY --- <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINIY'W PRIVATE DOMESTIC WELL/54>.'. PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> , ..:.._.,,. .,.,.,..--•-----•--- p <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS ►V, <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I/� 4 'b I a_� <br /> T Irrigation Gravel Pack Depth of Grout Seal�r�^ <br /> _ Cathodic Protection .., Rotary Type of Grout ' <br /> - Disposal Other Other Information <br /> Geophysical Sur ace Seal Installed B : <br /> r , <br /> PUMP INSTALLATION: 'Contractor 51 <br /> Type of Pump H.P. . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> Y <br /> PUMP--REPA-1R:- -// Sta`te Work Done <br /> AESfiRUCTION OF WELL: ,Well Diameter Approximate Depth <br /> ~Describe Material and .Procedure t: <br /> I "hereby agree .to comply with all laws and regulations 6f 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 a new 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 <br /> information .is true to the bt £ m k owledge _and belief. I WILL CALL, FORA GROUT INSPECTION <br /> PRIOR T O ANWA FIN I PE <br /> SIGNE TITLE <br /> ( RAW PLOT,-PLAN-.ON.REVERSE SIDE <br /> T; FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY _ - 1.DATE Z �. <br /> ADDITIONAL COMMENTS: <br /> 'PHASE II GROUT INSPECILION P g I/FINAI. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �� DATE :/l 78 <br />