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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOROFFICE ,USE: 1601 E. Hazelton Ave:', Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> A <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �. <br /> THIS PERMIT EXPIRES 1-FYEAR .FROM DATE ISSUED Date Issued ! <br /> 12 <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 workllherein described. - This application is made in compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules .and_.Regulation,s:.of the San Joaquin Local Health District. <br /> ,r <br /> ii <br /> JOB ADARESS/LOCATION.. A _ PCENSUS TRACT <br /> it 'oIC tT 51&*/y <br /> Owner's Name _yV.._1V.. z i"0 ® \tlE2::5_ _TA1 C - P i <br /> hone <br /> p - .. f <br /> Address f1' .. .:. ./� .. . .. � _.,,. ... <br /> �. .Q � ..� � ., _ .�.-,.: _:_ City <br /> u <br /> r <br /> d <br /> Contractor's Name.� � License Phone/P* <br /> TYPE OF WORK (Cheat): NEW WELL '] DEEPEN /_7RECONDITION /_7DESTRUCTION /7 <br /> PUMP INSTALLATION Y/ PUMP REPAIR /% PUMP REPLACEMENT J <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD � C SE S OOL/SEEPAAGE PIT &?,p_- OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL Ms PUBLIC DOMESTIC WELL 1L' <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �' Cable Tool ' <br /> Dia. .of Well .Excavation r <br /> &'r Domestic/private .°it DrilledDia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /�jL <br /> Irrigation .'Gravel Pack Depth of Grout Seal Q - <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposal I" Other Other Information <br /> Geophysical II Surface Seal Installed BY: �AIQQWT <br /> PUMP INSTALLATION: Contractor, ' l <br /> Type of Pump f :j �. _, H.P. <br /> 4. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `.REPAIR.• /7 State-Work Done, _ <br /> z <br /> aS;TRUCTION OF WELL: Well Diameter Approximate Depth Q <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 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 /> 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> ii (DRAW PLOT PLAN ON REVERSE SIDE _ <br /> ' 4 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .0- <br /> 1 -� <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION k PHASE TII/FINAL INSPECTION <br /> INSPECTION BY 0-_ DATE f INSPECTION BY DATE )-R -? <br /> E H 1426 Rev. 1-74 1-74 2M <br /> 111. _r• r <br />