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,4 49 <br /> I" QUIN LOCAL HEALTH DISTRICT <br /> FOR!'OFFICE USE: 1601 E. Hazelton .Ave. , -Stockton, Calif, <br /> .. . , - Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74h. <br /> THIS PERMIT EXPIRES:.1 YEAR-FROM DATE ISSUED Date Issued <br /> ► (Complete, In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> anti/or; install the:�:work herein described. This application is made in compliance with San Joaquin <br /> County'.Ordinance Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB.ADDRESS/LOCATION � ,.,; ��J�rc� CENSUS TRACT 1 <br /> Owner's Name i II �lr� - tr �s� e_ �Y.s Phone <br /> Address ._ .: ..: = City <br /> Contractor's Name 4L. License #�,r07 c Phone r �� { <br /> s <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN -/-7 RECONDITION /7 DESTRUCTION (7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR k7 PUMP REP CEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <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 /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/priyate Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> -� Irrigation Gravel Pack ' Depth of Grout Seal t <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ±� Surface Seal Installed By: <br /> PUMP INSTALLATION:i Contractor— _. 4, <br /> Type,of Pump ��- .p H.P. <br /> PUMP .REPLACEMENT State Work Done <br /> PUMP REPAIR: State Work Done <br /> .,RE&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 San Joaquin-Local Health District a <br /> WELL DRILLERS REPORT'bf the well and notify them before putting the- well in use.. The above <br /> information is rue to the-best.of. my knowledge and belief.',-.I WILL, CALL(FOR A GROUT INSPECTION <br /> PRIOR TO GR A iGfNS CrTIO t-., --F E 4 •� <br /> SIGNED OZ c TITL C—d <br /> �. (D PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE LY <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 DATE >� <br /> E H 1426 Rev:` 1-74 <br /> 1-74 2M <br />