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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t �-- - <br /> F094OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i.5� <br /> THIS PERMIT EXPIRESJ YEAR FROM DATE, ISSUEDW Date Issued <br /> rj. (Complete In Triplicate). <br /> Application is hereby made to h <br /> pp y the San Joaquin Local fiealth� District for permit --to construct <br />' P S 'tact <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 //�' CENSUS TRACT <br /> Owner 9 s NameP 0114 Phone <br /> Ir <br /> Address City ` " 8 <br /> I <br /> Contractor's NameLicense <br /> � c � <br /> /�' ���__I�,tG pha <br /> � Ile; <br /> j TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION /;7 PUMP REPAIR, /—/ PUMP REPLACEMENT . 1 <br /> Other J_7 <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES - PIT PRIVY . <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />` PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC'WELL <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation `r <br /> Domestic/private Drilled Dia. of Well Casing <br /> t = Domestic/public Driven Gauge of Casing p <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> , <br /> Cathodic Pr_otectlon Rotary Type of Grout <br /> x �Disposal , Other Other Information <br /> --Geophysical Surface Seal Installed B <br /> y.77 <br /> _. - 9' - <br /> PU3-P INSTALLATION.. Contractor <br /> Type of Pump <br /> H.P. <br /> i- r 1 <br /> P+�'ip REPLACEMENT: / / State Work Dane <br /> E&TRUCTION OF WELL: Well Diameter 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 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..the. well in.use.. The above <br /> information is t t of knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> -PRIOR TO GR D A FIN SP ION. <br />'. SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY(,- ! DATE <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II 4LUUINSPECT1014 PHASE III F NSPECTIO <br /> INSPECTION BY ,,, DATE L , INSPECTION BY TE <br /> r kyr <br /> ' E -H 3.426 , 'Rev. 1-74 1-74 2M..w <br />