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U) SAN JOAQUIN LOCAL iEALTH. DISTRICT <br /> FOF OFFICE USE. 1601 E. Hazelton`}Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> In Triplicate)(Complete P ) 2SS- Ogp a3 <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'' —�- &,,- 4 Vu, 1, 2-, GC6 CENSUS TRACT <br /> Owner's Name a - b Phone _ <br /> Address t C �&� e�., City 4/.t" <br /> Contractor's Name --A"ALIFx License # I9D 713 Phone 'j <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN %�/ RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT /-7 <br /> Other 11-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -/O0! PIT PRIVY ^C, <br /> SEWAGEIDISPOSAL FIELD /&2f CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 0 <br /> Domestic/public Driven Gauge of Casing fa aA--? <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection Rotary Type. of Grout <br /> Disposal Other Other Information zlv�71h4zj "W4 -j <br /> Geophysical Surface" Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /: / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 <br /> and the State of California pertaining to orregulating 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 Rf. my .knowledge and belief. I WILL CALL FOR A GRO T INSPECTION <br /> PRIOR TO G OUTING AN A NAL IlfSPEC710N. <br /> SIGNED /L , ITL <br /> D Pt T LAN 'ON RE SE SIDE � <br /> FOR,DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE-7— <br /> ADDITIONAL <br /> ATE7ADDITIONAL COMMENTS:%, <br /> P E 41,; N INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />