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�✓ � A <br /> FOEUSE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 I YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date, Issued <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> and/or instal. the work herein described: This application is made in compliance with San <br /> County Ordinance,No. Permit to construct <br /> 1$b2 and the Rules and Regttlations o the San 3o u n Lo 1 Health District.Joaquin <br /> JOB ADCATION <br /> �.fc� ,�tJ � �s� 2,� <br /> CENSU TRAG'�� <br /> Owner's Name �J Y <br /> Address Phone S— <br /> F <br /> City f'imr �-rre <br /> Contractor's NsmeS4V1*/P// -� <br /> License # � -7v-A Phone <br /> TYPE OF WORK (Check): NEW WELL 'L7 DEEPEN '/7. RECONDITION /_7 DESTR . <br /> PUMP INSTALLATION / PUMP REPAIR ' tTCCEME rf <br /> / <br /> Other / � PiTA7P REPLACEMENT <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWAGE DISPOS L'IELDWER LINES � PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT- OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL <br /> Industrial CONS TRUCTION-SpECIFICATIQNS <br /> Domestic/private ---"—` Cable Tool Dia. of Well Excavation <br /> Domestic/public Drilled Dia. of Well. Casing <br /> _ �_ Driven <br /> Irrigation Gauge of Casing <br /> Cathodic Protection —"— Gravel. Pack Depth of Grout Seal <br /> _. _� Rotary Type of Grout <br /> Disposal Other <br /> Geophysical cal Other Information <br /> _ -�--�— <br /> Surface Seal Installed BL <br /> PUMP INSTALLATION: Contractor <br /> 6.1 <br /> Type of Pump a � ` <br /> _ ✓ " H.P. C2j <br /> PUMP REPLACEMENT: State Work Done <br /> k <br /> Pi7MP .REPAIR: f /[/ State Work Done JlE <br /> lES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby, agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Lnd 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 I <br />[ELL DRILLERS REPORT of the well and notify them before putting.- the -well in .use... The above <br /> nformation is true to the.best-o€- my.knowledge_and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GRe TNG AND A FINAL INSPE 10 l <br /> IGNED r�' <br /> I / ._- +I TITLE . _d., <br /> DRAW PLOT-PLAN ON REVERSE SIDE) <br /> RASE OR DEPAK17M4NT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: <br /> PHASE II GR O INSPECTION <br /> JSPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION BY j <br /> - DATE <br /> E H 1426 Rev. 1-74 <br />