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G SAN JOAQUIN LOCAL HEALTH DISTRICT • .. M <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit..No. �gjJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /_I-L3.?7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the wotk /rein 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 /> JOB ADDRESS/LOCATION24zd CENSUS TRACT <br /> Owner's Name i - / Jfia..r Phone <br /> Address City <br /> Contractor's Name License # 24!?�hon5/ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / I DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE4 rRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br /> Industrial Cable Tool Dia. of Well Excavation ft'J_'_ _ O <br /> _ )o(,.. 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 �L�C Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor 44 <br /> Type of Pump 49 H.P. <br /> PUMP REPLACEMENT / / State Work Done _ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 taining to or regulating well'�construction. Within FIFTEEN DAYS <br /> after completion of 6my w on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o the weld. and notify them before putting the .well in use. The above <br /> information is t the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT I <br />" SIGNED TITLE <br /> ARA <br /> W PLAo— <br /> AN 'ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY (� • DATE /Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/F1114 INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> • <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />