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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7��S-P <br /> Telephone: (209) 466-081 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 771-31511-,l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued G <br /> (Complete in Triplicate) 027-off?.-1-15' <br /> 'Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .wand/or install the work herein described. This application is made in compliance with San Joaquin <br /> Ccunty�Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> � �" frt' r -"" 1�`�'�'2-'q�'1► � � 1v2s9-Z �7� � G''' /i/1i5�3,�f=�j <br /> .TOB ADDRESS/LOCATION f-2 CENSUS TRACT <br /> Owner's Name &M�2, ,l" ALV )24(01& L ff�, j'„ Phone J Y-~' �40�- <br /> Address / '�, City . fz <br /> r Contractor's Name 3 Zd <br /> � - < ilk d �1 cense-# Phone; <br /> 5—lz J161- 6 <br /> R 1 - <br /> TYPE OF WORK (Check): NEW WELL L7" DEEPEN /"'RECONDITION /-7 'DESTRUCTION /-7 <br /> PUMP INSTALLATION /.�/ PfIM�?_REPAIR /—/ ,,,.PUMP-,REPLACEMENT . ./.7-. n, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKI� SEWER LINES PIT PRIVY <br /> SEWAGE`DI-SPOSAL FIELD CESSPOOL/SEEPAGE.-PIT OTHER <br /> PROPERTY-LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> — INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool ""Dia. of Well Excavation <br /> Domestic/private Drilled '.Dia. of Well Casing <br /> Domestic/public Driven _. Gauge of Casing 4 p € <br /> Irrigation a �' .,Gravel Pack r Depth of Grout Seal `. <br /> Cathodic Protection Rotary Type of Grout i , <br /> Disposal FOther Either Information ' <br /> Geophysical Surface Seal Installed By: e <br /> PUMP INSTALLATION: Contractor,., <br /> F Type of Pump - -14- iy _H.P. <br /> PUMP REPLACEMENT: / / State Work Done r_ <br /> PUMP :REPAIR: /-7 State Work Done -' t <br /> ES;TRUCTION OF WELL. Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 my work on a new well, I will furnish the Sate Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well an' d notify them before putting the. well in use.. The above <br /> information is true to thembest of. my.knowledge and belief. - I- WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROWING AND A FINAL INSP ION... . <br /> SIGNED I&XTITLE �11r <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -/ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �/f DATE <br /> } ;E H 1426 Rev. 1--74 1-74 9M <br />