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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-r6781 J, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ` J (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 Joaquit <br /> County Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> E <br /> JOB ADDRESS/LOCATION , APV?,Ro)� NkAk k"4 CENSUS TRACT <br /> Owners Name `'aTC)GQ I`f %a^S 1 V\//�� (� Di a.� .G:�. Phone <br /> Address=- R0. '1 5-7 `a 0Q=i CA Ci57-05 City <br /> f Contractor's Name � License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -7 RECONDITION /_71MESTRUCTION <br /> PUMP INSTALLATION L_/ PUMP REPAIR /? PUMP REPLACEMENT 1 <br /> Other f / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C <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 l <br /> '"Industrial n 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 of Grout Seal <br /> Cathodic Protection Rotary Type of Grout . <br /> r �-- <br /> ` ' iir tDispose} Other ' oaion <br /> Geophysical :� �� Surface Seal Installed BY: <br /> I . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / /i State Work Done T <br /> r PUMP ''REPAIR: State Work Done <br /> ,RES•TRUCTION OF WELL: Well' Diameter Z \,NeLt..S 1 -" 1 i� { 14" Approximate Depth-;-W, +'110" <br /> Desc ibe Material and Procedure ILS. ji2 w n4iN ` W', c.F-Xi ,0 <br /> I hereby agree to comply with all 1 ws and regulations of the San Joaquin Local Realth District <br /> and the Stateiof 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'6� 'the well and notify them before puttingthe-.well in use.. The above. <br /> information-is true t6 t-he st'of myknowledgend belief. I WILL CALL FOR 'A 'GROUT INSPECTION <br /> PRIOR TO GR UTING AND !A R AL _INSPECTION.41-H-•! -1!1 <br /> j�� . <br /> SIGNED - 7.r7 TITLE 'a,(*h1_ 'lel C3-,I <br /> DRAW'PLOT'PLAN ON REVERSE SIDE) ` <br /> OR DEPARTMENT USE ONLY <br /> } <br /> PHASE I <br /> APPLICATION ACCEPTED-BY="". "" "�` ,w. '�' ' D"ATE / 6� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTIONRASE-III. F -INSP TION-----, <br /> INSPECTION BY DATE ' INSPECTION B DATE °i16 <br /> '€ ' � E H 1426., Rev. Ir74 1-74 2M _. <br />