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r <br /> �I) SAN JOAQUIN-,L0CAL"HEALTH DISTRICT <br /> FOF�:O FICE USE: 1601 E. Hazelton"Ave. ,,Stockton, Calif. <br /> Telephone': (209) 466-6787. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7�. _�J <br /> THIS PERMIT' EXPIRES 1 YEAR FROM .DATE "ISSUED Date Issued <br /> jtn.2 <br /> i' (Complete In Triplicate) <br /> Application is hereby 'made to the San Joaquin Local flealth .District for a permit to 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 Regielations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �: } &J CENSUS TRACT. <br /> Owner 's Name - p I �- . . . _ � Q! . .. , <br /> Phone _ 2 3-323` <br /> `- <br /> Address City <br /> .Contractor's. Name ' License ." Phone " s2� / <br /> t TYPE OFµWORK (Check): NEW WELL ' DEEPEN '/ 7 RECONDITION F7 DESTRUCTION 17 <br /> PUMP INSTALLATION "�J PUMP REPAIR "/ PUMP REPLACEMENT 17 <br /> 0"thee <br /> y <br />� DISTANCE TO NEAREST: SEPTIC ;TANKSEWER LINES PIT PRIVY <br /> SEWAGE -DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �R <br /> PROPERTY LINE PRIVATE DOMESTIC WELL'-, PUBLIC DOMESTIC WELL <br /> k INTENDED USF TYPE OF WELD; CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of Well Excavation <br /> -1/ Domestic/private Drilled Dia. of Well Casing <br /> Do:aestic/public °Driven - Y A -Gauge-of-Casiag <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protectionv.. Rotary Type of Grout ' <br /> Disposal Other .- Other Information <br /> Geophysical. Surface13"l� Ingtalled B r <br /> PUMP INSTALLATION: Contralto <br /> Type of Pump &r S,P. <br /> PUMP REPLACEMENT: . L-1 State Work'.Doie."I ` <br /> PUMP !REPAIR: /7 State Work <br /> O <br /> DESTRUCTION OF WELL.: Well Diameter Approximate Depth <br /> Describe Material"hand Procedure m <br /> I hereby agree to comply with all laws and regulations of ,the San Joaquin Local Health District <br /> and the State of California pertainingtoor regulatirig .well''construction. Within FIFTEEN DAYS <br /> after completion of.,my work on a new well;;il ..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 belie€. I WILL CALL `FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING 'AND A NALI1NS CTION <br /> SIGNED TITLE <br /> i (DRAW OT PLAI SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I r .. <br />, APPLICATION ACCEPTED BY DATE., <br /> FADDITIONAL CoM NTS; - .— <br /> P S I GRO INSPECTION PHASEI FIN INSPECTION / <br />` INSPECTION BY DATE YINSPECTION BY DATE p <br />. .., E ..R 14.26_ . Rev. 1-74 x :J 7 1t�YY�. h/95 .2M <br />