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.._,P r <br /> -+ <br /> �aSAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FO$rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> a • Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PU11P PERMIT Permit No. -;2 41) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued6-6--T�4 <br /> (Complete in Triplicate) Z28- -ftb- 221_ <br /> Application is hereby made to the San Joaquin Local Health Dietxic"t for a permit to construct � <br /> and/or" install the work herein described. This application is made in compliance with San Joaquin y <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> s. <br /> JOB ADDRESS/LOCATION . - 99 <br /> Ix CENSUS TRACT <br /> Owner's Name - Phone <br /> Address �? City !, <br /> Contractor's NameCZ.. License # Phone f22Z-jL20el 2t-/ <br /> /U3% <br /> i <br /> VTY OF-WORK (Check): _NEW WELL '/j?' DEEPEN "/7 RECONDITION /-7 DESTRUCTION f7 T <br /> PUMP INSTALLATION /—/ PUMP REPAIR /7 PUMP REPLACEMENT I? <br /> Other L/ <br /> 1 <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 /> Industrial Cable Tool Dia. of Well Excavation <br /> ^ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection" Rotary Type of Grout 46, <br /> Disposal .E Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION; Contractor u.�... ' � C1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L7 State Work Done <br /> PUMP :REPAIR: L-1 - State Work Done r� T <br /> M&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 true to the-best-of- my knowledge and belief. I WILI. CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING 2LKR 46 FINAL I PECT ON. <br /> SIGNED . TITLE t <br /> 0,0-/(DROM PLOT LAN ON REVERSE SIDE t, <br /> T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT Y DATE 3 - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE J411FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br />{ <br /> 1-74 2 <br /> E H 1426 Rev. 1-74 <br />