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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> "Applicationis <br /> 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �54 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> made to� the San Joaquin Local Health District for a permit to constructk 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 11 CENSUS TRACT <br /> Owner's Name All <br /> _ Phone 307 <br /> Address <br /> City � <br /> Contractor's Name } License # Z2a& Phone g- -QR07 's <br /> TYPE OF WbkkK -chi C'k) : NEW WE•L.L�/`'/ —DEEPEN / / RECONDITION / / DESTRUCTION /_ � <br /> PUMP INSTALLATION / / PUMI'_jEP_g1R _/ PUMP_REPLAC_EMENT <br /> -0- r _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES s ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CE5`SPO0L/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC -WELL PUBLIC DOMESTIC WELL <br /> INTENDED':USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industrial ;' 1 <br /> tCable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing LA <br /> Domestic/public Driven Gauge of Casing I . <br /> irrigatiori� Gravel Pack Depth Of.3;qrout Seal r� <br /> Cathodic Protectpe ion- Rotary Tyof Grout "� <br /> Disposal Other Other Informat iq;n <br /> Geophysical + Surface: Seal ilns,talled By: <br /> PUMP INSTALLATION: Contractor , <br /> Type ofm Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done t � ` <br /> PUMP ,.REPAIR: State Work Done 10,i2 i -� <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 F <br /> and the State of California pertaining to or regulating we11 construction. Within FIFTEEN DAYS <br /> after completion.._af,..my w-ork.-oni*a nem,w.e,l- ,_-I-.Wk€uTn-Ys+r-'t-lre 5-an--J,aa-q&in- --ocat--Health District a <br /> WELL DRILLERS REPORT of the wp11` and notifyw'th`em before putting- thewell in use. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING �AF�NICTION.SIGNED TITLE <br /> (DRAWPLOT PLAN ON REVERSE SID ) } <br /> FOR DEPART <br /> PHASE I MENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE IIRI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 <br />