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f: <br />! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I FOR,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 l YEAR FROM DATE ISSUED Date Issued -17-24 <br /> k �' (Complete In Triplicate) C&T__ 0 Ftl)- 10S <br /> I Applicatioxile hereby mill 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 -�o�.f `®® � <br /> �-P ENSUS TRACT , <br /> L�L� <br /> Owner's Name Phone �--�p t._z1. <br /> Address City <br /> contractor's Name License #I!L 373 Phone3l6k-A734- <br /> TYPE OF WORK (Check): NEW WELL;/-7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR - -PUMP REPLACEMENT /_ <br /> } Other ,l I _ .� <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES PIT PRIVY in <br /> SEWAGE DISPOSAL FIELD-, CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE —PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ;. CONSTRUCTION SPECIFICATIONS <br /> . 'Industrial .. E Cable Tool " Dia: of Well Excavation <br /> Domestic/private t Drilled �'Dia:_of Well Casing <br /> Domestic/public t Driven € [ Gauge of Casing <br /> Irrigation Gravel Pack -Depth of Grout Seal <br /> Cathodic Protection ► Rotary ,Type of Grout ' <br /> Disposal - t Other s A Other Information ' �- <br /> Geophysical Surface Seal Installed 'B ., <br /> PUMP .INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done t <br />' PUMP ;REPAIR: ateF Work Done �,�.�C.[ - - <br /> AV <br /> DES;TRUCTION OF WELL: Welk. Diameter Approximate Depth ^ <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 <br /> WELL_DRILLERS REPORT of the well and notify them before putting. the..well. in.use.... .The above <br /> information is true to:the-bas -of my..knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTIN D A FINAL NSPECTION <br /> SIGNED f <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br />' <br /> APPLICATION' ACCEPTED BY <br /> DATE 12 <br /> ADDITIONAL COMMENTS: ; <br /> PHASE Ii GROUT •INSPECTION PHASE I INAL INSPECTION <br /> INSPECTION BY. DATE { YNSPECTION BY DATE 2y <br /> E H 3.426 TtPv_:.. 1-74 r f./-7C �ou <br />