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SAN JOAQUIN LOCAL HEALTH-DISTRICT ' <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. .' Stockton, Calif. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Lc, <br /> ` 76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE:ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is'hereby made to:the. Son Joaquin Local Health District for B permit to construct <br /> and/or instar. the work herein described. This application is..made in compliance with Salt Joaqufn� <br /> County Ordinance No. 1862 and the- Rules .and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS AOC BION £ lu��t��S TRACT <br /> - <br /> .r... r+ / <br /> Owner's Name G�-ui� Phone — L G <br /> Address D— /G City <br /> Contractor's Name License #l�(,-L 37] Phone Y6 C-FC LJ' <br /> TYPE OF WORK (Check) NEW WELL -& DEEPEN '/7 RECONDITION l_'T DESTRUCTION fgf <br /> PUMP INSTALLATION PUMPkREPAIR /_7 PUMP REPLACEMENT /7 # <br /> R-.. Other Y_7 <br /> .DISTANCE TO NEAREST: SEPTIC TANK r 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 .2 le" <br /> Domestic/private . Drilled Dia. of Well Casing & <br /> Domestic/public Driven Gauge of Casing " c <br /> i Irrigation _ Gravel Pack `. Depth of Grout Seal -516 <br /> .. <br /> Cathodic Protection. Rotary Type of Grout , <br /> j Disposal Other Other Information <br /> Geophysical y Surface Seal Installed B : . <br /> PUMP INSTALLATION: Contractor . <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DES;!RUCTION OF WELL: Well Diameter Approximate-Depth 2 <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 /> E 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..we11. in.use... The above <br /> ` information true to the• est of- my knowledge and belief.. I WILL L 'FOR A GROUT INSPECTIONf <br /> PRIOR TOG U N AND A F INSPEGT -- <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIVEOf <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> 4 PHASE If'GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _.°. INSPECTION BY DATE �Iy� G <br /> 5 sr tf 1L9ti Qbn_ 7_74 _ .._. <br />