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f1OPIKOFF.I� . USE: <br />JOAQUIN LOCAL HEALTH DISTRIC' <br />Hazelton Ave., Stockton., Ca' if . <br />Telephone: (209) 466--6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />THIS <br />Application is hereby made to <br />and/or install the work herein <br />County Ordinance'No. 1862 and <br />JOB ADDRESS/LOCATION <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t <br />(Complete In Triplicate) F <br />L E eGGF <br />the San Joaquin Local Health District'for a permit to construct <br />described. This application -is made in compliance with San Joaqu: <br />the Rules and Regulations of the San Joaquin Local Health. District <br />�ci1l-�-• _ CENSUS TRA. T <br />Owner's Name L ��EC'� "_�,_---- .. _ Pftone <br />Address F /-d Mg- _ City `5T��',l.;TCj/�/ . 9 . �2G'C <br />Contractor's Name ?/I?��1 I /ELL_ 7J%�/L lU jx License #::F�37a. <br />TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /—/ DESTRUCTION /-7 _ <br />PUMP INSTALLATION / / PUMP REPAIR / / PITMP REPLACEMENT <br />Other <br />DISTANCE TO NEAREST: <br />SEPTIC TANK �D SEWER <br />LINES 4-e7e-_� PIT PRIVY_ <br />-- <br />SEWAGE DISPOSAL FIELD <br />CESSPOOL/ SEEPAGE PIT <br />- OTHER <br />PROPERTY LINEoi'RIVATE DOMESTIC WE.LLA�1 PUBLIC <br />DOMESTIC WELL <br />-' <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION <br />SPECIFICATIONS <br />Industrial' <br />_ < _ Cable Tool <br />Dia, of Well Excavation <br />% Domestic/private <br />Drilled <br />Dia, of Well Casing <br />�7 ,• <br />Domestic/public <br />Driven <br />Gauge of Casing <br />A Irrigation' <br />Gravel Pack <br />Depth of Grout Seal <br />p �' <br />Cathodic Protection Rotary <br />Type of Grout ��-,��t•r" (2 <br />Disposal <br />Other <br />Other Information <br />Geophysical <br />Surface Seal Installed By: <br />PUMP -INSTALLATION: <br />PUMP REPLACEMENT: <br />Contractor _ <br />Type of Pump <br />State Work Done <br />PUMP REPAIR: / / State Work Done <br />DESTRUCTION OF WELL: <br />_-H -4P. <br />Well Diameter _ Approximate Depth <br />Describe Material and Procedure <br />I^ <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" <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 G OUTING AND A FINAL INSPECTION. <br />SIGNED TTTT.R A - ._7X� <br />f <br />PHASE I <br />APPLICATION A <br />ADDITIONAL CO <br />INSPECTION BY <br />V. E H 14'26 <br />FOR DEPARTMENT USE <br />INSPECTION <br />Rev. •1-74 <br />6/77 _ 2M <br />