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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ? FOf OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f <br /> 1/, Telephone : (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V-255 <br /> THIS_PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 6 `j7 <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 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 w , -�'��-�� -°{� CENSUS TRACT <br /> Owner's Name `ZQ .` ,�i_���r f __° 1 '�s�.-� .�4:. Phone ��� � <br /> Address ��� r���� r ( : City <br /> l <br /> Contractor s Name �� / License 4Afl > Phone ! off <br /> 17 <br /> r TYPE OF WORK (Check) : NEW WELL f / DEEPEN /_/ RECONDITION /_/ DESTRUCTION =/_7 <br /> PUMP .INSTA LATION REPAIR "/ / PUMP REPLACEMENT / <br /> Other, / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation <br /> Domestic/private .P Drilled Dia. of Well Casing <br /> C Domestic/public i Driven Gauge of Casing <br /> Irrigations Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout l` <br /> Disposal 1 Other Other Information <br /> �` Surface Seal Installed By: <br /> Geophysical � - Su <br /> i PUMP INSTALLATION: Contractor <br /> Typed£ Pu ! jam- H.P. <br /> mp <br /> PUMP REPLACEMENT: /, State 'W'ork Done <br /> PUMP .REPAIR: / / S tate 4 Wo rk Done <br /> DES•TRU_CTI.ON OF WELL: -k -Well Diameter,- -----Approximate Depth---,-- <br /> •� - -�� <br /> mDescribe Material_ and Procedure <br /> iI 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I D <br /> APPLICATION ACCEPTED BY DATE G' z a '� <br /> ADDITIONAL COMMENTS: <br /> PHASE II' GROUT INSPEC PHAS /FINAL INSPECTION <br /> , INSPECTION BY DATE INSPECTION B . DATE - Z - <br /> '�, <br /> E H 1426 Rev. 1-74 ��- <br />