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."". -��r-...tom" .� .,.� �.,.. _-.�•.-.-: _�, <br /> .4. SAN JOAQUIN LOCAL HEALTH DISTRICT �5 <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED= Date Issued 1011117-7 <br /> (Complete In Triplicate) <br /> Application is hereb7. made to the San Joaquin Local Health District .for a permit to construct Sr <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 /a y ,J CENSUS TRACT <br /> Owner's Name Phone —„� <br /> Address 26 12 C11City £��� � a <br /> a <br /> Contractor's Name <br /> _- License� �o�Phone <br /> TYPE OF-WORK (Check) : NEW WELL fi4'/ DEEPEN /_/ RECONDITION / / DESTRUCTION— <br /> PUMP <br /> ESTRUCTION/PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK . �� ' SEWER LINES 6S'i PIT PRIVY <br /> SEWAGE DISPO AS` L FIELD �" CESSPOOL/SEEPAGE PIT may. OTHER -Z7- <br /> PROPERTY LINEiePRIVATE DOMESTIC WELL _ja_ PUBLIC DOMESTIC WELL 1 ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ` Gravel. Pack Depth oGrout Seal- <br /> Cathodic Protection Rotary Type of4Grout rQ,,,, e JT <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installedell <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done~ <br /> 3 <br /> DESTRUCTION OF WELL: Well Diameterpr� inate 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. thwe,1 in use.... The above <br /> information is true to the best of my knowledge .and belief. T WIe.LL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINA INSPECTION. .�._ <br /> SIGNED _ TITLE <br /> ( 0T PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I ti <br /> APPLICATION ACCEPTED BY , DATE /0 <br /> ADDITIONAL COMMENTS: •,, <br /> PHASE II.., UT INSPECT roN PHASE III IN INSPECTION # <br /> INSPECTION BY :4TE INSPECTION BY DATE <br /> J b/ /q /-7r7 � 1,A, <- r A P�jr)e el- C7/tn <br />