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4 Ii <br /> k / SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOR OFFICE USE. +� 1601 E. Hazelton Ave., Stockton Calif <br /> I <br /> Telephone: (209),.'466-6781 'K-� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 ,YEAR:FROM DATE#:ISSUED Date Issued !r`s <br /> - (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Locale Health District for a permit to construct. <br /> and/or install the work herein described.. This -application islmade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and:;Regul.ations_of thelSan Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I' z CENSUS TRACT f <br /> Owner Q s Name _..1Y1��" ��p�ip � � _.._..._— Phone A �G! <br /> Address .�� � ' ccr�c ...,v 1' ` -----~ City C <br /> Contractors Name <br /> ' License Phone 's-"� aJ� <br /> ri <br /> �. <br /> TYPE OF WORK (Check): NEW WELL/ EEPEN J-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR /7 TPUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER/ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL-_1 PUBLIC DOMESTIC WELL <br /> INTENDED USE .j TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial able Tool Dia. of Well Excavation `s <br /> =�__ Omestic/private Drilled Dia. of Well Casing ..; <br /> Domestic/public Driven Gauge of Casing /p ^' <br /> Irrigation Gravel Pack Depth of Grout Seal -6-01 - d <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _Other Information <br /> Geophysical -Surface Seal Installed BY: cY.'�T <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump M H.P. <br /> PUMP REPLACEMENT: . .,„.%/State ,WorkDone � <br /> PUMP .REPAIR <br /> // State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter i Approximate Depth <br /> Describe Material;and Procedure �. 1 <br /> I hereby agree to compl)r 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 iwewell, I`Will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS. REPORT of! the well and notify idem before putting. the .well in use.. The above . <br /> information is true to the-best of my knowledge and belie �f[WR <br /> f. IILL CALL FOR GROUT INSPECTION <br /> PRIOR TO GROUTING A I FINAL SPECTION. I I <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE) SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPEC IO <br /> INSPECTION BY DATE INSPECTION BY DATE 13 <br /> 1 E H 1426 Rev. 1-74 ` 1-74 2M <br /> r y - <br />