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f� ��•�A <br /> A Ip <br /> sF: r. <br /> mo w <br /> Y i � <br /> f <br /> Y _ <br /> SAN JOAQUIN:LOCAL HEALTH DISTRICT <br /> FDli3OFFICE USE 1601 E..:Haselton Ave.,. Stockton, Calif. >k <br /> r� •{." ` " :Telephone.' . (209),:4f5-6781 <br /> ��{{J} ' APPLICATION FOR`.WELL CONSTRUCTION -OK PUMP PERMIT Permit No <br /> ' a` ', ; r THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED Date <br /> (Complete .In..Triplicate) _ Y� <br /> Applicationlis hereby`mide'ttolthesSan:Joaquin.Local' Health.District,ior apermit to construct <br /> sad/or install the work herein described. This application:is made'.in compliance with-Sas Joaquta <br /> Couaty.,v Qrdiaanle No. 1862 aad the Rules. and Regulations 'of the'San Joaquin.;Local Healeb Diattlet. `� <br /> JUH ADD7. <br /> RESS/LOCATION'' -CE.vSUS TRACT = a �r <br /> Hi <br /> 2 o <br /> . Ovner s Name11,242 14 Phone ,L 30 9 hF <br /> Address City /Erma b <br /> ' �. <br /> Contractor'a Name / i,icenae - Phoneme /G3% <br /> X TYPE OF idORK (Check) .NEW WELL f DEEPEN I'7 :RECONDITION /7 DESTRUCTION ./? 'S <br /> w °PUMP'sINSTALLATION / /; .PUMP REPAIR /'7 PUMP REPLACEMENT 17 <br /> DISTANCE TO NEAREST SEPTIC.TANK;ONC- -. SEWER LINES-. PIT PRIVY <br /> x " ` SEWAGE:'DISPOSAL%EIELII:`' IW CESSPOOL/SEEPAGE PIT OTII$lt F r ` <br /> sPROPERTY'LINE -'PRIVATE-DOMESTIC WELI. PUBLIC DOMESTIC`WELL ` <br /> °{ i .INTEND® USE TYPE OF WELI: CONSTRUCTION SPECIFICATIONS <br /> x7 Industrial <br /> "' Cable Tool Dia. of, Wall Excavation: z <br /> Domc:etic/Private Drilled Dia. of Well Casing = <br /> Domestic/public - Driven Gauge of Casing y <br /> t Y�'t Irrigatlaa `; Gravel Pack . <br /> :Depth of Grout Seal ' <br /> ;r - .. P l3tr7P <br /> Catradic Pro taction'_ Rotary > ' Type of Grout­­_ �10n� <br /> ' Dispob.'1 Other. Other Information hy, ncc1n�� f <br /> :7777=Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor. prt <br /> raG�� i <br /> Type.-of Pump. H:P <br /> C <br /> = PU1SP`REPI:ACEMM: <br /> / / State Work'Done <br /> �'' PUMP ,xEPAIR� State Wark Done <br /> ' -- "f <br /> DESS UCTION OF WELL Wel .Diameter Approximate De' ' <br /> Describe Material and Procedure: <br /> I hereby agree to comply-with all.laws and.-regulations of the San. Joaquin.Local..Health;-District <br /> State of-California <br /> andithe ..pertaining�to or. regulating well-construction '>Within:FIFTEEN IKS <br /> after pletion'of-:my'work.on a new i:eZl, I will furnish the San Joaquin.Local 'Health District la , <br /> W$LL;DRILLERS:REPORT:`of 'the_4elland notify them before putting the weli'.,in use.: The above <br /> information,is "true°to the best of my knoule,:ga and belief. I WILL CALL FORA GROUT'INSPECTIO <br /> _PRIOR='TO Gr.UTING AND'A'FINAL INSPECTION. <br /> SIGNED - TITLE <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE), <br /> csrrra» <br /> FO EPARTMENT USE ONI-�, <br /> APPLICATION'ACCEPTED BY . r. <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC Ql P S 'I/FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY tG� —DATE <br /> d <br /> h <br /> (� 7 <br /> E H .1426 Bev. I-74 J, �" ti }/f(7' 2Ii <br /> f <br />