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�I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT'­- 1. <br /> FOA rOFFICE USE- 1601 E. Hazelton Ave. , Stockton, Calif. ': <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> OL <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �­` Date Us ued3 S' <br /> (Complete _In Triplicate) <br /> Application is hereby made to the Safi Joaquin Local Health District for'-a'pev t,'to construct, al <br /> and/or install the work herein described. This application,is made. n compliance with, San Joaquin.. <br /> County Ordinance No. 1862 and the Rules and Regulations of the- San Joaquin"toc'A %Health_ Di:strict: 7 <br /> 1 s <br /> JOB ADDRESS/LOCATION qG - t. �; '. CENSUSTRACT <br /> Owner's Name C. y Q Y' Phone <br /> VV <br /> Address Z O Ly City... 1 <br /> Contractor's Name hwulLicense lad 794 Phare <br /> r <br /> TYPE OF WORK (Check); NEW WELL & DEEPEN /-T RECONDITION /-T DESTRUCTION ET <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT W <br /> z Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Le�a. 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 /> 4 Industrial Cable Tool " Dia. of Well Excavation <br /> Domestic/private " Drilled Dia. of Well Casing j+ A V C <br /> Domestic/public Driven ^ Gauge of Casing <br /> Irrigation Gravel Pack- P ` Depth of Grout Sea + . <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> III PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP i.REPAIR: /� State. Work Done . _ _ <br /> PES;TRUCTION OF WELL: Well Diameter y Approximate^Depth / r <br /> t ,Describe. Material and Procedure <br /> J <br /> I hereby agree to comply with all laws and re ul ons of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. WithiniFIFTEEN 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 CAL FQR 'A GROUT INSPECTION <br /> PRIOR TO GR NG AND A FOAL JNPECTION. { <br /> SIGNED } TITLE r <br /> 9 (DRAW PLOT PLAN ON-REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION.ACCEPTED-BY DATE -z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION -1 ; PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r DATE 6r <br /> E H 1426 Rev. 1-74 I-74 2M <br />