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_ SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> EOF OFit--ECUSE- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;?7 ld 30 <br /> 7) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /S <br /> Q <br /> I (Complete In Triplicate) /,03-2,30--(j, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct 4 <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 ZLIell 'CENSUS TRACT t <br /> ZY-I '/1.17 <br /> Owner's Name Phone <br /> Z4 q--"235,0 <br /> Address -7 Cit`�0 � 1 Y + <br /> Contractor's Name License #,o_2 Phone el <br /> s <br /> _ _ x <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP REPLACEMENT /_7 <br /> Other '/, / O <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ;E <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 'a <br /> Industrial �- Cable Tool Dia. of Well Excavation / r� _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation :I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type„of Pump H.P. 7 <br /> PUMP REPLACEMENT / / State Work Done , <br /> PUMP -.REPAIR: / / State Work Done O i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health I <br /> and the State of California pertaining to or regulating well construction. Within FIFT <br />' after completion of my work on a new well, I will furnish the San Joaquin Local Health WELL DRILLERS REPORT of the well and notify them before putting the..well in use.. The a'finformation is true o the best of my knowledge and belief. I WILL CALL FOR A GROUT IN <br /> PRIOR 7GROUTING A FINAL 'IVqjEff ION. <br /> SIGNED A TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />' PHASE I 4 <br />. APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY, DATE Z- P, 24'__ <br /> E H 1426 Rev. 1-74 <br />