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1 <br /> 1 <br /> C� SAN .TMQ►►IN LOCAL HEALTH DISTRICT <br /> F06 OFFICE USE: 1601 l:. Hazelton Ave. , Stockton, Calif'. <br /> 'telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 29--a7 <br /> Tris FERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued At— <br /> (Complete 9�6 <br /> (Complete In Triplicate) <br /> application is hereby made to the Snn Joaquin Local llealth District for a permit to construct <br />-nd/or install the work herein described. This application is made in compliance with San Joaquin'. <br />-ounty Ordinance No. 1862 and the Pules and Regulations of the San Joaquin Local Health District. j <br /> iOA ADDRESS/LOCATION Si :;(QLi * T � CENSUS TRACT <br /> wner'9 Name ��� - Phone 3op <br /> dewe QI 1 J City <br /> n � 9 a-9 G �. / —t <br /> tractor's Name License Phon��� <br /> SPE OF WORK (Check): NEW WELL / % DEEMN /7 MCONDITION /—j DESTRUCTION f7 <br /> PUMP INSTA-I LATION7 P7?'­PUMP REPAIR /7 PUIp REPLACEIWIT /-7 <br /> Other / / — <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \n t <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ____ PLBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation R ► <br /> Domestic/private Drilled Dia. of Well Casing ,\ <br /> Domestic/public _ Dr vQn Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal G <br /> Cathodic Protection Qotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Byi <br /> tMP INSTALLATION: Contractor <br /> Type of Pump H.P. Z <br /> en <br /> r <br />-T REPLACEMENT: / / State Work Done 4 <br /> j <br />*M 'REPAIR: /_7 State Work Done <br />_TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> 7encribe Material and Procedure ► <br />-ereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> q r <br /> the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> er completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />-L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />-ormation i true to�F � <br /> best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> )R TO'GR G N:,PECTION <br /> EN <br /> ED TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DFtiPARTMENT USE ONLY <br />�ICA�TION ACCEPTED BY DATE <br /> METIONAL COMMENTSt <br /> PHASE II GROUT INS CTION PHASE LII F NAL INSPECTION <br /> VECTION BY DATE INSPECTION BY 4DATE 77Z 7 Al <br /> E: H 1426 Rev. 1-74 h/75 2M <br />