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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOE OFFICE USE: O)d- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 7 t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 77 a <br /> (Complete In Triplicate) rowrct ';Ow fc-polr e4)i_r <br /> Application is' hereby made to the San Joaquin Local Health District for a permit tc) construct <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 /> k <br /> JOB ADDRESS/LOCATION [ & /Y1 L y"lc i¢VE,_ _ /A -ECA CENSUS TRACT + <br /> Owner's Name .0 A)-'TGpAI I J_OAf/VSQN � � Phone 32 Vq! � <br /> Address - --- - -.i�".4E City / �EG•9_, <br /> Contractor's Name AllMCh- 400�, �IAC-z License '#2 Phone fZy <br /> E <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / J RECONDITION /_J DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT f? <br /> �- Other <br /> s. <br /> DISTANCE TO NEAREST: S PTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD FQ i CESSPOOL/SEEPAGE PIT OTHER t <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED -USE- '-a- --TYPE-'0E-WELL-- = ' µ CONSTRUCTION-SPEC IFI CATIONS <br /> Industrial Cable Tool Dia. of Well Excavation .� <br /> Domestic/private Drilled Dia. of Well Casing _ C I' <br /> Domestic/public Driven Gaiige �'of''Casiizg <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ` - Cathodic Protection � Rotary Type of Grout <br /> Disposal Other--- Other Information <br /> Geophysical k Surface.Seal Installed By; __ _" C& <br /> PUMP INSTALLATION: Contractor `# ' { � f� <br /> Vt <br /> Type of Pump y HSP, j <br /> � I <br /> PUMP REPLACEMENT / / State Work Done <br />:PUMP--.-RERAIR.; S.tate,rWork_DoneC <br /> DESTRUCTION OF ,WELL: Well Diameter ,�%-t 1% ? r Approximate Depth <br /> Describe Material and'Procedure `` l <br /> .5. <br /> I hereby agx e_to_comp.ly with...'all. laws and .regulations of the San Joaquin Local Health District ! <br /> and the State of Califor'nia.. pertaining to or.regulating well 'construction. Within FIFTEEN DAYS f <br /> after completian-�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 M <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT'. INSPECTION <br /> PRIOR TO GR TING 00D�o FINAL SPECTION. <br /> SIGNED TITLE <br /> DRAW PLIDT PLAN 'ON RE FRSE SIDR <br /> "Ile" FOR DEPARTMENT USE ONLY <br /> PHASE I !� t <br /> APPLICATION ACCEPTED.Bf DATE �' 46 7 <br /> ADDITIONAL COMMENT '2' 52 fazy - <br /> PHASE II GRO -EC ON v PHASE /FINAL INSP4ECTION <br /> INSPECTIQN BY 1 DATE INSPECTION BY DATE <br /> 2M' <br /> E H 1426 Rev. 1-74 <br />