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'� o wt6G SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAOFFI E USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> x <br /> .,� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 0 0 -( Ct TnN (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 Aot,` r J a CENSUS TRACT Z_0.3--0W,0`/.1 <br /> Owner's Name _ __ e a►�� iY O Y n�.g-�r r___. _ Phone <br /> Address S3 Y e;c 4)a�a 4c' - -' city (39,1-d <br /> Contractor's Name �. ,. �i License # tg l'Mone <br /> k <br /> a <br /> TYPE OF-WORK (Check): NEW WELL 7 DEEPEN '/-7 RECONDITION /_7 DESTRUCTION FT ro f <br /> PUMP INSTALLATION /7 PUMP REPAIR / PUMP REPLACEMENT 1 O <br /> Other <br /> L1 !` <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 it <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 4 . k <br /> Domestic/private Drilled Dia. of Well Casing <br /> r --- Doimestic-/public - —Driven---- <br /> Irrigation <br /> ----Driven Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information r <br /> Geophysical Surface Seal Installed BY: <br /> i � 3 <br />. PUMP INSTALLATION: Contractor <br /> Type of Pump ~'~ '' H.P. <br /> :PUMP REPLACEMENT: L/ State Work Done, s <br /> ,s <br /> PUMP :REPAIR; State Work Done iC f3f 4 f, -IZ*,,iw � , ne ja -awl=- . <br /> ,DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> - Describe Material and Procedure• <br /> } f <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 /> WELT, DRILLERS REPORT of the well and notify them before putting.-the- well in.use.. The above <br /> information is true to the-best my kn ledg d belief. I WILL CALL FOR A GROUT INSPECTION F <br /> PRIOR TO GWZTING AND A FINAL I ION <br /> SIGNED _= E. ITLE iA r <br /> PL LAN ON R ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'PHASE I <br /> APPLICATION ACCEPTED BY DATE I--I5-=7�- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHAB II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION; BY <1 DATE — <br /> E H 1426 y <br /> t Rev: 1-74 1-74 2M <br />