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SAN JOAQUIN LOCA -HEAR -=t "STRICT <br /> OK:OFFICE USE:, 3601 E. Hazelton Ave. "`Stockton Calif. <br /> I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 76 <br /> (Complete In Triplicate) C),0,5,- _374D -4D3 <br /> Application ig =hereiiy :made Co 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 Joaqui <br /> County Ordinance No. 1862 and.*the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION SJ "r©f,6, 4,t . ;Z S S TRACT <br /> Owner's Name j t , <br /> i - Phone <br /> F <br /> Address - i' City , ^� <br /> t . ; �. � <br /> Contractor's Name � " =� � License # � hone; <br /> TYPE OF WORK (Check): NEW WELL/�77­bEEPEN;/? tRECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION%!-/�P REPAIR-/ PUMP REPLACEMENT <br /> ` Other <br /> F DISTANCE TO NEAREST: SEPTIC TANK QQ SEWER LINES PIT PRIVY. 0 <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ' OTHER <br /> "T PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �T <br /> INTENDED USE ; w .. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , t 7 bible Tool Dia. of Well Excavation <br /> IIbmestic/grivate . .. Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing <br /> Irrigations. Gravel Pack't. Depth of Grout Seal <br /> Cathodic Protection . � Rotary;;°�<" - Type of Grout <br /> Disposal Other Other Information <br /> 7C7—Geophysical �. ;Surface Seal Installed 'B <br /> PUMP INSTALLATION: ` Contractor``'/ <br /> # , Type'.of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / S.i to Work Dane <br /> PUMP !REPAIR: � �` <br /> State Work Done <br /> i 2E&TRUCTIW OF WELL: Well Diameter � Approximate Depth <br /> Describe Material and Procedure <br /> Z;;hereby agree to comply with all laws and regulations of the San Joaquin LocalHealthDistrict <br /> and the State of California pertaining to'or regulating well'•construction. Within FIFTEEN DAYS <br /> after completion ofimy work on a new welkj 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 GROU AND A VWU INSPECTION. I <br /> 4 SIGNED t TITLE <br /> 4 1 DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ABY DATE ' 2 Z!2 <br /> ADDITIONAL COMMENTS: 0 1 <br /> -- _PHASE_ jf GROUT-INSPECTION- PHASE gII FINAL INSPECTION <br /> INSPECTION BY r.DATE INSPECTION.-BY toll, DATE ® � 3 <br /> E H 1426 ltev. .1--74 h/7q 2M <br />