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E F <br /> I- 1 SAN JOAQUIN LOCAL-.HEALTH DISTRICT --`-- <br /> FOF�iOFFICE USE: 1601 E. Hazelton 'Av&" S,tockton, Calif. <br /> Telephone: ..i(209) 46667.$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;4,/, <br /> THIS PERMTT.EXPIRES 1 YEAR-FROM DATE ISSUED Date Issued <br /> (Complete ln`Triplicate) <br /> Application is herebymadeto the San Joaquin Local, ,Health-,..District for a permit to construct <br /> and/or install the work herein described. This appl.icatiorf is made in compliance with San Joaquin' <br /> County Ordinance No,.;1862 and the Rules and ,Regulati'ons',of,,ihe San Joaquin Local- Health District. <br /> JOB ADDRESS/LOCATION,, CENSUS TRACT <br /> � .. <br /> Owner v s YN'ame r�. } - Vin:-a. •, c <br /> Phone /go <br /> Address <br /> city <br /> 4kp <br /> Contractor's •,l <br /> Name <br /> `7 <br /> �! .. �£? License �ZjgZo Phone <br /> f <br /> TYPE OF WORK (Check):. NEW WELL F7 DEEPEN /7 -RECONDITION- /_7 DESTRUCTION /_7 <br /> ' f PUMP INSTALLATION /J_ PUMP REPAIR / / PUMP REPLACEMENT /S <br /> other C� <br /> DISTANCE TO NEAREST: SEPTIC {TANK SEWER LINESa 7 PIT PRIVY o • + <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE D(?MESTIC WE€,L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL .,, ,/,-CONSTRUCTION SPECIFICATIONS <br /> "Industrial '�:- <br /> Cable Tool Dia, of- Well Excavation �.04 <br /> Domestic/privateDrilled 'r­Dia. ,of-Well Casing C?'f <br /> Domestic/public Driven Gauge-o£ Casing <br /> t Irrigation ° " Gravel Pack Depth of Grout Seal <br /> Cath;di,;Piotection Rotaryp ' <br /> Type of .Grant <br /> Disposal t Other '_ Other Information r <br /> i Geophysical V Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> J�ESIRUCTION OF WELL: Well Diameter <br /> •_— i 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 EP_dRT,of-thw-kki acid motif them before <br /> Y putting. the. well in use.. The above <br /> information is true%to�the-be�t'/bf 'my knowledge and belief I WILL CALL FOR 'A 'GROUT INSPECTION <br /> PRIOR TO GROWTING AND FINAL I INS PE CT ION. <br /> SIGNED .TITLE <br /> i DRAW PLOT PLAN ON REVERSE STD44 <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTSor: <br /> PHASE II GROUT INSPECTION PHAS INAL INSPECTION <br /> INSPECTION BY DATE ;INSPECTION BY DATE <br /> E H 1426 Rev, 1-7,4 <br />