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r <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE1* 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />` JOB ADDRESS/LOCATION I N0 LIM K L S CENSUS TRACT <br /> ! 4t_L l !f 3 15Z-C> <br /> Owner's Name I1vI DGqEN � LL /}e_tfi R RD Phone <br /> Address t� 1 � ` City <br /> c - <br /> Contractor's Name ©VSlNE_=f;�_ , License # Phone <br /> TYPE OF WORK (Check) : NEW WELL' /-_T DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATIONI'% /`JPUMP REPAIR I I PUMP REPLACEMENT <br /> Other <br /> 4 DISTANCE TO NEAREST: SEPTIC TANK Sfl SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - 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 W\1Cathodic Protection Rotary Type of Grout Dv <br /> Disposal Other Other Information.' <br /> Geophysical Surf ace,:.Seal Installed By.: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ LL.- 67,g/ r-y& H.P. <br /> _ jam Cl sl nlE=` W i n+_ C0NGZI✓7_�_ ?OP I r <br /> PUMP REPLACEMENT: / / - State Work Done _ S� ' eV� DAF"=Ci4s/1►�__E— � _ <br /> r $tF-e-o L4/ at-wo D LSV Ez_ rt . BAC <br /> KF1 <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 Cali€ornia' 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 Distridt 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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1 PRIOR TO WOUTING AND A FI INSPECTI N. <br /> SIGNED ZZTITLE <br /> W� P_L T PLAN ON REVERSE SIDE) <br /> w 4 r _ R DEPART NT USE ONLY <br /> r, .. <br /> PHASE I' - <br /> APPLICATION -ACCE �/� <br /> ADDITIONAL COMMENTS: <br /> PHASE-II GROUT 'INSPECTION P F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Gt?3/76 2M f <br /> j E H 1426 Rev. 1-74 <br />