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i _- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ok?OFFICE USE: VIZ1601 E. Hazelton Ave. , Stockton, Calif. l�C� <br /> Telephone: (209) 466-6781 �y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit m ,..31?GtJ <br /> THIS PgRMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue S� <br /> (Complete In Triplicate) 0&,,- 240-1 o <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 ii_l3of E--- CENSUS TRACT <br /> Owner o s Name 0A/_eV An Phone A/3 <br /> Address­ ,;),,4l � '� 9�a� <br /> city 132EA ,.CA41 je � <br /> Contractor's Name /"A_Cj4i3 T_-)4 _ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /j:TDEEPEN / RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION :/rUMP REPAIR / / PUMP REPLACEMENT L7 {' <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK "',SEWER LINES PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . - CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool f Dia. of Well .Excavation !�. <br /> . /Iomestic/private Drilled { Dia. of Well Casing % i <br /> Dome6tic/public Driven Gauge of Casing <br /> Irrigation ravel Pack .,Depth of Grout Seal <br /> Cathodic Protectionotar � ' ' " <br /> y.1 ~Type of Grout <br /> Disposal Other Other Information - <br /> Geophysical �` Dp <br /> -t.-.Surface-Seal -Installed, B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ SL�� - = H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PT31 -REPAIR: v --�/- / State Work Done <br /> ES•TRUCTION 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 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 /> (DRAW PLOT PLAN ON REVERSE SIDE . <br /> r `FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED' BYDATE a 7� k <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -INSPECTION BY DATE ! 'T�. <br /> T <br /> T <br /> E H- 1426 Rev. 1-74 <br />