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L ✓ SJLOCAL HEALTH DISTRICT 0 [PY <br /> FOR OFFICE USE: 1601 4>. Hazelton <br /> Hazelton Ave. , Stockton, Cali7:� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;V- 3 C/gl�' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 2F-7G� <br /> (Complete In Triplicate) <br /> kpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin. <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> TOB ADDRESS/LOCATION /�S6js--� Mf3dV7�� 7 CENSUS TRACT r <br /> timer's Name -e5 (5 )�`PF�A41 / 11y C. Phone <br /> Adress �o�� J . �J T1rl Y City <br /> ontractor's Name Zs7-jy License #A_-g73Phon4-4 (09'6 <br /> YPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION '�'�� PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY "1 <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/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 'jTMP INSTALLATION: Contractor L 7�9 Pf/'`-;77� <br /> Type of Pump y�n4r z H.T. <br /> JMP REPLACEMENT: / / State Work Done UJ-f- 0097 <br /> UMP .REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED P "� TITLE y, ; <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> BASE I <br /> PPLICATION ACCEPTED BY �� � / DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE 2?— <br /> E H 1426 Rev. 1-74 1-74 2M <br />