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ao SAN JOAQI3IN LOCAL"HEALTH DISTRICT <br /> FOR rOFFICE USE: 1601 E. Hazeltot►:;Ave. , 1S'tockton, Calif. <br /> Telephones.-;:`' (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS.PERMIT EXPIRES 11EAR,EFROM1�DATE ISSUED Date Issued ' 7 <br /> :(Complete. In:Triplicate) .r <br /> Application is hereby made totheSan Joaquin Local Health District for a permit to construct i <br /> and/or install the workherein described:,?? This .application.is made in compliance with San Joaquin ' <br /> County Ordinance No.• 1867 .and" the_Rules and-,Regul:ations',of..rhe San Joaquin Local health District. <br />, JOB ADDRESS/LOCATION '�? o �/ y CENSUS TRACT -2-OS-160-O& <br /> Owner's Name M ale l ,a � , :�.. ., ?trJ as to `_ to S V1aw+- �#1.LE�✓ <br /> Phone <br /> Address -.: �a-/ ' - v_ n �,..w ..._. �_.... <br /> - '�cY"'=-�� -- City C t/ <br /> Contractor's. Name 7 ' License #� Phone <br /> 4 4 <br /> , <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/_�­ RECONDITION DESTRUCTION <br /> PUMP _ <br /> .INSTALLATION /. J PiFMP REPAIR A71PUMP REPLACEMENT 7 <br /> Other J/ ° k % 14 <br /> pP <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <br /> _ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE- PRIVATE-DOMESTIC WELL;- PUBLIC DOMESTIC WELL h <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well, Excavation <br /> Domestic/private �•, - Drilled = Dia. of Well Casing A . <br /> Domestic/public)] ;;Ii , riven' ' Gauge of Casing <br /> ,> <br /> all <br /> Irrigation Gravel Pack Depth of <br /> Grout-Seal <br /> a <br /> Cathodic ProEectlon Rotary" Type of .Grout - E <br /> Disposal �. 'T.y Other Other Information E <br /> Geophysics] rF Surface Seal Installed BY:IQ <br /> ` • <br /> PUMP INSTALLATION:� Contractor <br /> Type.'of Pump / H.P. <br /> PUMP REPLACEMENT: E7 State Work Done <br /> PUMP !REPA <br /> IR: jState 'WorkDonez j G Lam•. . -_, . <br /> e <br /> E&TRUCTION OF WELL. Well Diameter, . . d Approximate Depth <br /> '"' `� "Describe MAterial and Procedure p <br /> r- <br /> N:: ? , <br /> I hereby agree to comply. wirh all laws and regulations of the San Joaquin Local Health District f <br /> and the State of California pertaining to or -regulat, ng 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNED } TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE.ONLY - - <br /> � . <br /> APPLICATION ACCEPTED BY DATE i <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> , <br /> E H 1426 Rev. I-74 <br /> 1--74 2M ; <br /> f <br />