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yayV M - i <br /> G ' SAN JOAQUI.N LOCAL'.HEALTH* DISTRICT f <br /> FOE OFFICE USE:. 1601 E.; :Hazelton Ave., Stockton, Calif. <br /> j Telephone: x.(209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3�k <br /> THIS PERMIT -EXPIRES 1,YEAR FROM .DATE ISSUED Date Issued Z--7s <br /> . • } •n � " (Complete In Triplicate) <br /> Appli6ation is hereby made `to,-the San Joaquin Local Health Disttict for a permit to construct <br /> and/or .install the ,work herein described. This application.is made in compliance with San Joaquin <br /> County'0 dinanc Nn. 1862 -and the-,Rules and Regulations�ofrrhe San Joaquin Local Health District. <br /> z1�r2 D D # (p CENSUS TRACT <br /> JOE ADDRESS/LOCATION <br /> Owner's Name � or,n j n + ter'�'••� „"` -- Phone --; 2 3 D 3 <br /> . ,; .. � - . . City <br /> Address 13 a fO <br /> C--T 7 SbI <br /> License # 16a373 Phone ro6""q� � <br /> i Contractor's Name w. — K - - _ _ <br /> TYPE OF WORK (Check): NEW WELL -117' DEEPEN_ 7 RECONDITION /� DESTRUCTION-1-7 <br /> PUMP INSTALLATION 14 PUMP REPAIR /� PUMP REPLACEMENT I T <br /> Other. 1 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 /> f INTENDED USE . TYPE.OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q, <br /> Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation w,-Gravel Pack Depth of Grout Seal _S" `A4i <br /> Cathodic Protection &.-, Rotary Type of Grout t'��-rle�► �` 1� <br /> Disposal Other Other .Information <br /> , <br /> Geophysical _ -.. - Surface Seal Installed B E . Lu av- , <br /> PUMP INSTALLATION: Contractor �t <br /> Type'lof Pump H.P. 1 Oj2t <br /> PUMP REPLACEMENT: /DPP' State Work Done <br /> PUMP `.REPAIR: state .Work Done <br /> • We11. Diameter Approximate Depth _ -- <br /> ES;TRUCTION OF WELL. <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ing to or regulating well construction. Within FIFTEEN DAYS <br /> and the State of California pert <br /> i after compl ono ' i work o Ene, 11, I will furnish,-the San Joaquin Local Health District a <br /> WELL DRIL RS REPORT of thew 1otify them before putting. the..well in.use.. The above <br /> informati n is true o the.bknowledge and belief, ` I WILL CALL FOR A GROUTINSPECTION <br /> PRIOR TO OUT N A ON. <br /> SIGNED I TITLE a- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I DATE 'I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: i PRASE III FINAL INSPECTION <br /> PHASE II GROUT INSP TION <br /> INSPECTION BY A. DATE A "7r INSPECTION BY " -- DATE :,�`� •7,S`= <br /> 1-7 4 2I <br /> E H 1426 Rev. .1-74 <br />