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R r <br /> ' FOEOFFE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IC <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) Z --7� <br /> Application is hereby made to, the San Joaquin Local Health District permit _ <br /> for a t to construct <br /> and/or install the work herein described. This application is made in compliance with San Jo II <br /> County Ordinance No. 1862 an the Rules and Regulations of the San Joaquin Local Health District. <br /> Q117 ' <br /> 3 .;. E . : g <br /> JOB ADDRESS/LOCATION � `�' ��" I <br /> � r �CENSUS TRACT I <br /> Owner's Name r. ! <br /> - 7 Phone <br /> Address - <br /> �, City <br /> IlContractor's Name f License �� n. <br /> i b!/��Q Phone , fI <br /> TYPE OF WORK Check) ; i <br /> { NEW WELL / / DEEPEN / J RECONDITION /_% DESTRUCTION <br /> PUMP INSTALLATIONk; <br /> PUMP REPAIR L/ PUMP REPLACEMENT "D <br /> Other /-7- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CFSSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia, of Well Casing <br /> Irrigation lac Driven Gauge of Casing <br /> Irrigation I Gravel. Pack Depth of Grout Seal {' <br /> Cathodic Protection 1 Rotary Type of Grout ! <br /> _ yp <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed B : �i, <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump <br /> H.P. <br /> f. <br /> PUMP REPLACEMENT; State Work Done ��� • / L -2 � A <br /> PUMP .REPAIR: / J State Work Done <br />)ES-TTRUCTION OF WELL: Well Di meter <br /> Describe Material and Procedure Approximate Depth <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> TELL DRILLERS REPORT of the well and notify them before putting the -well in use.. The above <br /> Information is true to the bestlof my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G TING AND FINAL INSPECTION. <br /> iIGNED -7 TITLE <br /> i � ail <br /> (DRAW PLOT PLAN ON REVERSE SIDE ! <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> ,> a <br />.PPLICATION ACCEPTED BY _ ._; .._ �,�, DATE - f-]> <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPEC ION <br /> NSPECTION BY �- DATE INSPECTION BY DATE <br /> E_H 1426 Rev. 1-74 <br />