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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> 7el <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4Ls-�� <br /> (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 wore 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 O );Cc, /Al L E yCENSUS TRACT 15-57 <br /> I <br /> Owner's Name d ly A L C-C L Phone <br /> Address <br /> � L` !� , �' city ? k c <br /> Contractor's Name LN--c License #I_azEff6 Phone ga3-y-3,7U <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /-7 RECONDITION /-7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION /-f PUMP REPAIR /-7 PUMP REPLACEMENT f <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES/4eLftt PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT OTHER y <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � - <br /> ,Domestic/private i---Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ri <br /> Cathodic Protection Rotary Type of Grout aEIYf E11( <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: ti f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S ly Ac� c� cc! u jff' L j_ H.P P. 1_ 4 <br /> _ • t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'BEPAIR /7 State Work Done y <br /> kES,—T'RUCfION OF WELL: Well Diameter Approximate Depth f <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 true to the best-of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE z + <br /> DRAW PLOT PLAN ON REVERSE SIDE) J <br /> FODEYARIMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE _ DATE <br /> ADDITIONAL COMMENTS: <br /> f FINAL INSPECTION <br /> INSPECTION BY SE II GROUT INSPECTION _ INSPECTION BY-PHASE IDATElam_ <br /> _.._. ,... <br /> t E H 1426 Rev. 1-74 1_74 } <br />