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1 SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> F0, OFFICE USE: !� 1601 E. Hazelton Ave. , Stockton, Calif.: . , <br /> Telephone: (209) ,46-6-6 7.81 <br /> Ih -APPLICATION `FOR WELL CONSTRUCTION OR PUMPPERMITPermit No. <br /> F <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued :�'7e <br /> (Complete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and%or install the work herein described. This application is. made in compliance with San Joaquii <br /> County Ordinance No. l$62 and the Rules and. Regulations of the San Joaquin Local- Health District. <br /> Ii <br /> TOB ADDRESS/LOCATION CENSUS TRACT: <br /> } <br /> Owner's Name ._ /f� � "_ Phone ' Ilal. <br /> ` Address ��� City - — <br /> ,iL C✓ <br /> Contractor's Name1� (� �ene ' Phoney <br /> TYPE OF WORK (Check) : -NEW WELL ./. I DEEPEN/ / RECONDITION %/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION //'PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> Ir DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'w-�Y-.`. PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD ,e ' CESSPOOL/SEEPAGE PIT OTHER <br /> lPROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ! Industrial Viable Tool Dia. of Well. Excavation0 77— <br /> ► L---Domestic/private. Drilled Dia. of. Weil Casing <br /> Domestic/public Driven Gauge of Casing— <br /> Irrigation <br /> asingIrrigation Gravel Pack Depth of Grout Seal s <br /> k Cathodic Protection Rotary Type of Grout <br /> Disposall ' Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> f �, . L <br /> f PUMP INSTALLATION: iContractor <br /> ` jType,.of Pump . H.P, <br /> ' I 4 tiwa <br /> PUMP REPLACEMENT: , / / State Work Rorie'-. '3 <br /> k PUMP .REPAIR: / / State Work Done <br /> ° D.ES=TRU�TION� WELL.__- Well Diameter Y Approximate Depth <br /> . <br /> Describe Material and Pxo'declure.,-_ L <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 myf,work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well 'and notify-tfi'eifi'before"putting. the. well in use.. . The above <br /> information is true toithe best of my knowledge and belief. I WILL CALL;°FOR A GROUT INSPECTION <br /> PRIOR TO GRO G D A FINAL INSPECTION <br /> SIGNED _ TITLE <br /> 1� (DRAW PLOT PLAN ON REVERSE SIDE)PHASE �:' ' . " t. `�• ' __ <br /> FOR DEPARTMENT USE ONLY ,# <br /> APPLICATION ACCEPTED BY y -� , DATE <br /> ADDITIONAL COMMENTS: <br /> P.HAU ROUT INSPECTION P!t4kiii/FINAL INSPECTION 1 <br /> INSPECTION B1. DATE 'Q-1 INSP.,ECTION-,,,_B '' DATE <br /> E H 1426 Rev. . I-74 __ <br />