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0.0 <br /> rSAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> a <br /> 11 OFFICE USE: .. 1601 E. Hazelton. Ave: , Stockton, Calif. <br /> Telephdi a (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &_/11 <br /> }� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t <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 21 f O 2 S. L A rl 1 C R s . R A. R A c Y CENSUS TRACT R <br /> Owner's Name A iV,. �, s-/1-v,ER1 A w Phone g 3S- SI 7 { <br /> Address -.'- . )33q7 /11 0119 ROA Q City-- - _C_ _ r <br /> Contractor's Name H,6AIMINg: BA?os, h000sry License # 29481.3 Phone 5221031 <br /> TYPE OF WORK (CY:eck) :. NEW WELL -LV DEEPEN -/-7 RECONDITION /� DESTRUCTION f7 <br /> PUMP INSTALLATION 0.. PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> s Other <br /> DISTANCE TO NEAREST: SEPTIC TANKg IOQ' ISEWER LINES5 PIT PRIVY � t <br /> SEWAGE DISPQSAL FIELDS CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE,"I. PRIVATE DOMESTI&WELL 110� PUBLIC DOMESTIC WELL \ <br /> INTENDED;USE PE 0 .i WELT, {" CONSTRUCTION SPECIFICATIONS fI <br /> Industri/al wCable Tool Dia. of Well Excavation 12 <br /> X omestic/Private X ]Drilled Diai. of Well Casing <br /> omestic/public � y Driven Gauge of Casing D � - <br /> rrigation ✓ Gravel Pack Depth of Grout Seal <br /> athodic�Protectiont Rotary Type of Grout--' <br /> isposal . . i; i ter Other Information <br /> Geophysical 'Surfe Seal Installed B 4:.}, <br /> QE�� Zv41* / 0 <br /> PUMP€\ASITALLATION: 'Contractor - - -- -- -� <br /># - - Type of Pump H.P. <br /> PUMP REPLACEMENT: fState.°Work Done I <br /> PUMP REPAIR: - / State-Work Done <br /> - ` ` <br /> i 'tiOu , <br /> ' } Approximate De k <br /> j3ES'TR CTION OVWELL: ,Well Diameter f pP Depth <br /> P71 <br /> r I Describe Matet''i-a and-"Procedure <br /> I hereby agree to comply with-al-111aws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaitiing.�A or_regulatiag well construction. Within FIFTEEN DAYS <br /> after completion of^qty woIi�on a new well;Twill furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of-the-we11 and-notify them-zbdfore putting the-well in.use.. The above <br /> information is true to'the best-of- my knowledge and �elief.\I WILL CALL FORA GROUT INSPECTION <br /> k PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> !. SIGNED TIV E` v U N E + . <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I = <br /> li <br /> ;APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMEkNTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIONI / <br /> INSPECTION�,BY <br /> 4 i DATE INSPECTION BY , DATE /--/ ]' <br /> R-H 1426 Rev. l r,7 4 <br /> 1-74 2M <br />