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WL <br /> OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh: <br /> 1601 E. Hazelton Ave. , Stockton, Cal <br /> if. <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. <br /> i X <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued 7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i and/or install the work herein described. This application is made in .compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Josquin .Locel Realth District. <br /> 30B ADDRESS/LOCATION ,/ A..)vcl ojrf2GS ,ca , CENSUS TRACT <br /> Owner's Name `�,�.r ( Lfa rir� fl Phone <br /> 'Address City * <br /> I Contractor's N License # t 3-7)4—Phone y--?67G <br /> f <br /> 77 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN A/7 RECON <br /> I?ITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other /% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p <br /> Industrial Cable Tool Dia, of -We-11 Excavation <br /> Domestic/private Drilled Dia, of Well Casing Q <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 /> I <br /> PUMP INSTALLATION: Contractor <br /> 'Type 'of Pump H.P. <br /> PUMP MEm . / State Work Done- <br /> PUMP ,REPAIR: / / State Work Done ^I <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with awl laws and regulations of the San Joaquin 'Local Health District <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, Twill furnish the San Joaquin 'L•ocal Health District .a <br /> MELL'DRILLERS REPORT of the well and notify them before putting..the well in.use.. The above <br /> ;information is true to thebest of my owle Se d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL IN ETIO <br /> :SIGNED ,_ri rvo e.1V TITLE <br /> f 'D W PLOT PLAN ON'4ftRSE SIDE <br /> 1PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . i <br /> PHASE II GROUT INSDICTION 'PHASE . I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 <br /> _ Rev. 1-74 E_1-,r ,,,, <br />