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- s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - -- <br /> FOF�iOFFICE USE.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> " APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7g <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED Date Issued <br /> (Complete In Triplicate) V Q 1'-- V2a-0 Z <br /> Application 'is hereby made tdithe San Joaquin Local Health District for a permit to construct <br /> and/or install the.work herein described. This application is made in compliance with San Joaquinr <br /> County Ordinance No.,.,1862 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2» l�dasa o n �as�rrL� a c. 1 ( CENSUS TRACT <br /> Owner s s Name Phone <br /> Address _ "Q N 1':::QL.-Ek Te"L o - City �� p <br /> Contractor`s Name License # 1g3`?ZZ—Phone 6yw��l6 <br /> _ s <br /> TYPE OF WORK (check):. NEW WELL '/ / DEEPEN '/-7 RECONDITION /-7 DESTRUCTION f7 �} <br /> PUMP INSTALLATION PUMP REPAIR / /PUMP REPLACEMENT / <br /> .� <br /> Other'`J / <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 /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation - <br /> `,+ , Domestic/private,;,-, 1 Drilled Dia. of Well Casing 1 <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout + <br /> Disposal i Other Other Information i <br /> Geophysical Surface Seal Installed By_: <br /> PUMP INSTALLATION. Contractor std <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /37 State Work Done <br /> RfA <br /> PUMP .REPAIR: /7 State Work Done` <br /> E&T.RUCTION OF WELL: Well Diameter F 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 REPORT of the well and notify them before putting the..well in use.. The above <br /> information is true to the best of my knowle e a ief. I WILL CALL FOR'A 'GROUT INSPECTION <br /> PRIOR TO WUTING AND A FINAL INSP I p <br /> SIGNED �LE <br /> D W L T PLAN ON REVMft SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY `i DATE 2i <br /> . ADDITIONAL COMMENTS: 4z ' <br /> PHASE II GROUT'INSP TION PHASE 1aAqNAL SPECTIO <br /> INSPECTION BY DATE INSPECTION- BY ATE /Zl�g <br /> E H 1426 . Rev. 1-74 1-74 2M <br />