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Cc i-,PIPSAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOAr'0 F'ICE USE: �' �/1601E. Hazelton Ave. , Stockton, Calif. <br /> r , Telephone: -(209) 466-6781 <br /> ' APPLICATION*FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a��j6 <br /> f (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 made in compliance with San Joaquin <br /> CouAty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION &J&aa l o n -3 A/ CENSUS TRACT <br /> 4 <br /> i Owner's Name a "7- I Phone <br /> Address 'GL Ce r ` --� City Mrr.�o v44�f <br /> Contractor's Name �t r , License # l� -Phone k, 74 <br /> f _ <br /> TYPE OF WORK (Check) :`NEW'NEW WELL /� DEEPEN /� RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT /7 <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 /> f INTENDED USE TYPE OF WELL n CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> �y <br /> �C Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> _ Cathodic Protection Rotary Type of Grout, <br /> Disposal Other Other Information <br /> Geophysics] Surface Seal Installed By: <br /> IN <br /> PUH' INSTALLATION: Contractor F s <br /> ` Type of Pump H:P. ].•r' <br /> PUMP REPLACEMENT: / / State Work Done <br /> ' <br /> PUMPIRE80ar State Work Done ,/� + � r- j MJ or <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply 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 Health District. a <br /> WELL DRILLERS REPORT of the well and notify theta before putting-the- well in ,use.. The above <br /> a information is true to the-best.of- m knowledge and belief. I WILL CALL FOR'A 'GROUT INSPECTION <br /> PRIOR T04LWZING AND A FIN I . <br /> SIGNED TLE . <br /> PLO "PLAN ON XMME SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE —' 2 <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYY-ADATE <br /> µE H 1426 Rev. 1-7-4 1-74L� <br />