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r � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> OFI'_I('E USf•:: 1601 R. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 'fIICS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby tn41d0 to the San Joaquin Local health District for a permit to construct <br /> Vin(i/or install the work herein described. This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. `` <br /> JOB ADDRESS/LOCATION �k, �f�tJlo K�>�ILlia"� Gas � ENSUS TRACT <br /> Owner's Name , Phone <br /> Address /���E,,� �, �Gn�.�e _ City Gd�� <br /> Contractor's Name ��_ License /y �Phonq <br /> TYPE OF WORK 'Check) : NE14 WELL /-7 DEEPEN ' RECONDITION /-T DESTRUCTION <br /> PUMP INSTALLATION UMP REPAIR /? PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINK: - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL= . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump b �.�_�f�� i H.P. <br /> PUM'_' REPLACEMENT: / / State Work Done <br /> + PUP[P REPAIR: / / State Work Done <br /> ^i DFSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />�z <br />� _ I hereby agree to comP]y with all laws and regulations of 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 Heath District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> lntormation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO GR 'D A FINAL TITLE SAN JOAQUIN POMP COMPANY <br /> SIGNED <br /> W PLOT PLAN ON REVERSE SIDE f <br /> FOR IRPARTMENT USE ONLY P. Q. Box 201 <br /> PHASE I �,g��p[Dja 95240[ (� <br />� API'I,ICATION ACCEPTED BY "IIATLr'�� <br /> ADD'TIONAL COMMENTS: <br /> PHASE II GIOUT INSPECTION PHASE iii FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY,,<,C DATE 21291, <br /> F. <br /> 77 <br /> H 1426 Rev- 1-74 b� <br /> ..v,,,y,r:� � .v«.rm.s�.•a.x..a.ra4 ,,...ww:�:aeca q.,f �.:"�&' �,�,/�p'��� sa'.; ' <br />