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. : SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160 <br /> °ruh.-OFFICE USE: 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> rAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. I' <br /> II THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;4L±_ <br /> (Complete In Triplicate). <br /> Application is hereby made to the San Joaquin Local 11ealth District for a permit to construct <br /> ; and/or install the work herein described. This application is made in compliance with Son Joaquir <br /> County Ordinance No. fit and' the Rules and Regulations of the San Joaquin Local Health District. <br /> r > ` /4� <br /> JOB ADDRESS/LOCATION . /4C CENSUS TRACT�// - �� . _ <br /> . Owner's Name "i ' E Er�� Phone , <br /> Address 3 3 C3 S City ' <br /> Contractor's Name AE eb POA'? License # 1r1,3H26 Phone y6 <br /> !i <br /> TYPE OF WORK (Check): 1NEW WELL �17 DEEPEN /� RECONDITION -7 DESTRUCTION /_T <br /> 'PUMP INSTALLATION " PUMP REPAIR'/ PUMP REPLACEMENT /T <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 /> --N <br /> ��Industrial 41 Cable Tool. Dia. of Well Excavation <br /> _ Nk Domestic/Private: Drilled Dia. of Well Casing <br /> �,. Domestic/public ;E Driven Gauge of Casing <br /> Irrigation Graved Pack' Depth of Grout Seal <br /> Cathodic Protection Rotary - Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed 'B <br /> i <br /> PUMP INSTALLATIONr :J1 Contractors mp r_(i:Rf�`" 's � �C. <br /> w.Type of Pump H.P. <br /> 4 PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: i� / / -State Work Done <br /> DESTRUCTION OF WELL: 1f. Well Diameter r= Y�'. :.. ..Approximate 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.`con6truction. Within FIFTEEN DAYS <br /> after completion of mywork on anew well, I will furnish the San Joaquin Laical Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting-the'..well. in"u`s`e.... .The above <br /> information is true to the-best:of my..knowl.edge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING°ANDA FINAL INSPECTION. _ , <br /> SIGNED I p TITLE?C . j ec �� <br /> DRAW PLOT PLANON REVERSE.,SIDE <br /> FOR DEPARTMENT USE ONLY + r <br /> •1'APPLICATION ACCEPTED BY E DATE <br /> ADDITIONAL COMMENTS: E <br /> PHASE II!'GROUT INSPECTION ,,. P I FINAL INSPECTION <br /> INSPECTION BY DATE * INSPECTION BY DATE - _1 9 <br /> r E H-1426 Rev." 1-74 ;l - 2M <br />