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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fpg OFFICE USE: V/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.; (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 'ntI PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued <br /> (Complete In Triplicate) 1-7-7-560-Ce <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -5-5 £ . ,mss tom•se-e :- <br /> .TOB ADDRESS/LOCATION Fisk �d %.Isr�v9,�. �� A,10 �`s ._ cENsus TRACT <br /> Owner r s Name 1,eLw r Phone <br /> ` L <br /> Address l��/' i_sl� City <br /> t ` i v Licens 4� hone �3/ 3 z/a <br /> Contractors Name <br /> TYPE OF WORK (Check): NEW WELL Q� DEEPEN J RECONDITION /? DESTRUCTION J-j <br /> A,• PUMP INSTALLATION .0 PUMP REPAIR REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES /ODS -' PIT PRIVY U) <br /> SEWAGE DISPOSAL FIELD O �/ CESSPOOL/SEEPAGE PIT OTHER �h <br /> PROPERTY LINE�PRIVATE DOMESTIC WELL/ 54PUBLIC DOMESTIC WELL <br /> -INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial { _ Cable Tool Dia. of Well Excavation /D ZesO <br /> y,Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven . Gauge of Casing 1 71//7 O <br /> IrrigationGravel Pack Depth of Grout <br /> _777 Rotary <br /> ' <br /> Cathodic Protection _ - Rotary Type of Grout 1 e �cf <br /> DisposalOther Other Information` <br /> { i <br /> Geophysical ✓ SurfaceSeal Instal+-led B : <br /> PUMP INSTALLATION. <br /> • Contractor _•,_�/�,ya <br /> Typeof Pump �� u6Gricr 6/ - B.P. <br /> T % --- <br /> t PUMP REPLACEMENT: / /! State Work Done i <br /> } PUMPtREPAIR: / / State Work Done <br /> ES:TRUCTION OF WELL: Well Diameter " Approximate Depth f <br /> Describe Material and'�Procedu{re/ <br /> I hereby agree to comply with- .411 laws and regulations of the San Joaquin 'Ldcal 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 `Aeal-th District a <br /> WELL DRILLERS REPORT of 'the weld_ 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 FORA`GROUTII�TSPECTION <br /> PRIOR TO GROUTING AND A; FI!2, SPECTION.-' . <br /> SIGNED TITLE opGv <br /> (DRAW,PLOT PLAN ON REVERSE SIDE) l '.. <br /> FOR DEPARTMENT USE ONLY I L <br /> PRASE IT <br /> APPLICATION ACCEPTED BY DATE; : -Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHASE III FINAL INSPECTION <br /> f INSPECTION BY DATE INSPECTIW-BY�C DATE <br /> EH 1426 Rev. 1-74 <br />