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r•'---rte-r s.mr .<- -.._._ ._ .. ��--_ �__ <br />- SAN JOAQUIN LOCAL 14EALTH DISTRICT <br /> FOArOI'FICE USE: .601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit'No. 261-21P <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /-).1-74 <br /> (Complete In Triplicate) <br /> Application'is hereby made to the San Joaquin 'Local health District for a permit to construct <br /> and/or install the work herein described. This application is wade in compliance with San Joaquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION N J.�- . = r �- al CENSUS TRACT <br /> Owner's Name Phone <br /> Address 7 _ Cityr - — <br /> License #16,x3 73-Phone <br /> Contractor a Name ,r.,,„�, _ _ <br /> , - - <br /> TYPE OF WORK (Check): NEW WELL/7--j�bEEPEN '/ / RECONDITION /-7, DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP 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 LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USETXPE OF WELDr CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation \ <br /> Domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public f Driven''',. Gauge of Casing <br /> IrrigationGravel.•Pack Depth of Grout Seal <br /> Cathodic Protection + Rotary , Type of Grout <br /> Disposal Other Other Information <br /> Geophysical e" Surface Seal Installed .-By: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Sia.t e Work Done <br /> PUMP REPi�IR: /- 'State-Wdr'k' <br /> ES;TRUCTION OF WELL; Well Diameter l ' ` Approximate Depth <br /> Describe Material and Procedure , <br /> t <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I 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 Health District-,'A <br /> { WELL DRILLERS REPORT of the well and notify them before putting the -well in.use.. The above <br /> information is true to the-best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRqWINGiAND A F INSPECTION. <br /> TITLE <br /> SIGNED <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> t {. : FOR EPARTMENT USEJONLY <br /> PHASE I g LF <br /> DATE <br /> APPLICATION ACCEPTED BY. <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUT I SPECTION \ PHASE III F AL INSPECTI N <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> ^E S 1426 Rev. 1-74 1-74 2M <br />