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F019*t0 F-ICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT --- <br /> ;� —�---- ' + 1601 E. Hazelton•_� I Ave. , Stockton, Calif. <br /> (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUNF PERMIT <br /> Permit t No. 7 /86 <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUES <br /> ` (Complete In Triplicate) Date Issued <br /> APPlicatian is hereby made 'to the San Joaquin Local Realth District <br /> f -and/or install the work herein described. <br /> County Ordinance- No. 1862 ,ah�d the Rules and Regulations of the for <br /> a permit to with <br /> Sa uct <br /> This application is made in compliance with San Joaquin <br /> h , _ <br /> San Joaquin Local Health District. <br /> 1 JOB ADDRESS/LOCATION /ls-�7 ,�A �• <br /> Owner's Name 1 CENSUS TRACT <br /> Address Phone <br /> . � <br /> city S <br /> Contractor's Name <br /> License # Ef )_�ana <br /> TYPE OF WORK (Check}: NEW WELL -/-T DEEPEN —PUMP /? DESTRUCTION /`-j <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other / � PUMP REPLACEMENT_ /-7 <br /> DISTANCE TO NEAREST: SEPTiCTRK <br /> SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSA�L FIELD _ <br /> PROPERTY LINE - PRIVATE'DOMES S /SEEPAGE PIT_ OTHER ~ <br /> ` INTENDED USE TYPE OF PUBLIC DOMESTIC WELL— <br /> __ Industrial WEi.L CONSTRUCTION SPECIFICATIONS t <br /> _ Domestic/Private —� _ Cable Tool Dia. of Well Excavation <br /> F <br /> , _ Domestic/public Drilled Dia. of Well Casing <br /> ",Irrigation --�— Driven Gauge of Casing <br /> Gravel Pack Depth of Gro <br /> Cathndi�c Protection _i Rotary ut Seal <br /> Disp a1 Other T Ype of Grout { <br /> �_Geophysfcal - Other Information <br /> PUMP INSTALLATION: Surface Seal Install <br /> � / 1 <br /> Contractor -�,��,�r/ •. <br /> Type of?Pump r,. •- <br /> PUMP REPLACEMENT: H.P. <br /> // State Work Done <br /> PUMP :REPAIR: <br /> 1r/ State" <br /> State Work Done <br /> DES-TRUCTION OF WELL. � <br /> Well Diameter <br /> Describe" Material and Procedure Approximate Depth <br /> -----�_ <br /> hereby agree to comply with all laws <br /> Ind the State of California pertaining to or regulating well cons <br /> and regulatiana of the San JaaquJLn Local Health District <br /> after completion of my work on .a new well, I will furnish the San Joaquin 'Loc <br /> TELL DRILLERS REPORT of the well and notify construction. Within FIFTEEN DAYS <br />.nformation is true to the-best* m them before al Health District a <br /> RIOR putting. the..wel1 in.use The above j <br /> NG AN Y wle a an belief. I WILL CALL FORA GROUT INSPECTION <br /> IGNE A FINAL INSPE IO <br /> } <br /> W P T LAN ON RE RSE STLE <br /> IDE <br /> RASE I DEPARTMENT USE ONLY <br /> PP CIL ATION ACCEPTED BY <br />)DITIONAL COMMENTS: <br /> PHASE II G <br /> TSPECTION BY EC N DATE <br /> PHASE I I/FINAL . i <br /> DATE INSPECTION $Y INSPECT N <br /> DATE <br /> E'N' 1426 . Rev. 1_74 i ' <br />