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'Q k <br /> SAN ..TOA UIN 'LOCAL" HEALTH DISTRICT <br /> FOk OFFZCE USE: 1601.E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 7�-/�/� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> i, 4 <br /> THIS PERMIT EXPIRES 1„YEAR FROM. DATE ISSUED Date Issued Z <br /> } <br /> (Complete In Triplicate). I <br /> Application is hereby made to the San Joaquin „Local Health Distri.ct,.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 ne-kl CENSUS TRACT <br /> Owner's Name �/, ;� ki Phone <br /> Address ��:.�. ... City Ar <br /> j <br /> Contractor's Name ! <br /> M License # j7?_ Phone ” <br /> j <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /w/ RECONDITION /_] DESTRUCTION /_7 <br /> AL _ <br /> PUMP INSTLATION REPAIR / PUMP REPLACEMENT <br /> Other <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 � <br /> INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS- <br /> Industrial ' 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public t_ %Driven Gauge of Casing ` <br /> �C Irrigation t =Gravel Pack Depth of Grout Seal mil] <br /> Cathodic Protection 1 Rotary Type of Grout \ <br /> Disposal i' Other _ Other Information <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: Contracto ,t}��i <br /> r, Type of Pump - ' H.P. Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> :... ' <br /> PUMP .REPAIR: /X/ State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and -Procedure _ <br /> I hereby agre* 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 "const.ruction. 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 G O TING AND A FINAL�IP T N. ; <br /> SIGNED l P. TLE <br /> zS <br /> P 0 AN ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY LATE <br /> ADDITIONAL COMMENTS: a,; <br /> PHASE 14 GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /e> / 7 <br /> E H 1426 Rev. - l-74 <br />