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ry 04 <br /> �s SAN .TOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR 0 F E USE: . 1601 E. Hazelton Ave. ,- Stockton, Calif. <br /> Telephone: (.209) 466--5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> P t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE''ISSUED Date Issued 3 / '7(I , <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 work herein described. This .application is made in compliance with San Joaquinx <br /> County Ordinance No. 1862 an the Rules and Regulations of the- San Joaquin Local Health District. <br /> JOB .ADDRESS/LOCATION. <br /> , �c�n CENSUS TRACT <br /> Owner's Name ty T Phone <br /> Address c/p .T4,.-acn a !",-44 D � A67 .1- City <br /> Contractor's Name ,�' 0 License `j/ 3 7)_{Phone <br /> i <br /> TYPE OF L+TflRK (Check) . NEW WELL '!—/ DEEPEN �/_/ RECONDITION ,�� DESTRUCTION /_7 � <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other ./ <br /> •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 /> INTENDED USE, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> lk <br /> 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__ -Rotary Type -of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ] <br /> Type of Pump a S H.P. �. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .- R: State Work Done �4o 4.,} L/ <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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP I <br /> SIGNED TITLE �LeL1"• <br /> W PLOT %LAN ON R RSE SIDE) <br /> R DETMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PIAS I /FINAL INSPECTION <br /> INSPECTION BY &ALLDATE INSPECTION BY DATE <br /> E H 1426 Rev. , 1-74 6177 _ ZM/ <br />