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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r_"`:'OFFIE'.USE: 1601 E. -TIazelton Ave. , Stockton Calif. ' <br /> TClep`h ne: (209)) 466"16781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ??-. [ / <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,$-/-7 <br /> (Complete In Triplicate) <br /> Appiication�ris 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 Joaquir <br /> r County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name,. a Phone %7 ^�.5-, <br /> 0.22 <br /> Address x }CI[�' "� <br /> ' City [~d6/wl,�JlJls <br /> N F <br /> Contractor's Namef License #,?�H6R Phone <br /> II ! , 11 <br /> - N <br /> TYPE OF : NEW WELL /1�DEEPEN '/_/ RECONDITION DESTRUCTION /_ <br /> i t PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7� Q <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK A AC SEWER LINES- PIT PRIVY a <br /> i': SEWAGE DISPOSAL FIELD CESSPOOL-/SEEPAGE PIT OTHER/YOn/f�' <br /> !' PROPERTY .LINE - PRIVATE DOMESTIC WEIX &,L. PUBLIC DOMESTIC WELL a' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> V , Domestic/private Drilled Dia. of Well Casing I* <br /> r Domestic/public Driven Gauge of Casing -,5e_,y 7VE Q <br /> ' Irrigation i Gravel Pack Depth of Grout Seal <br /> + Cathodic Protection Rotary Type of Grout f' <br /> ' Disposal Other Other Information FAJ <br /> GeophysicalIN <br /> k S.ur--f-ace-S,e•a-1 Installed--B, - - !-'7.. <br /> fi <br /> PUMP INSTALLATION: Contractor 'J, R <br /> Type3a£ Pump .A21 &A, i.Xz, -- •- H.P. : /�. . <br /> PUMP REPLACEMENT: / / State Work Done Zf 7-qzz /��C�L B F' n/Iyy /0 <br /> _. <br /> PUMP-REPAIR: .. State Work Done <br /> DESTRUCTION OF WELL: Well Diameterf <br /> . .s>,., - -Approximate Depth- <br /> Describe' <br /> epth-Describe Material and Procedure' <br /> I hereby agree to comply with all laws and regul`aytivons of the San Joaquin Local Health`District <br /> and the State of California pertaining to or regulating we11 '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 thecrell-and-no-t f-y-them before...putt-in-g—the---well -in-use..The above <br /> information is true to the bist of my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GP&IJIG ANDI CT ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE.I r.. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE '�' ''2 r7 <br /> ADDITIONAL COMMENTS: ; <br /> :PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY ti DATE INSPECTION BY 4zDATE <br /> E H 1426 Rev. 1-74 1I R 2M <br />