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FOF OFFICE USF. n D SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> z !j 1601 E. Hazeltun Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEpyIT Fermit No. i. <br /> THIS PERMIT FXPIRES 1 YEAR FROM DATE ISSUED , <br /> (CDate Issued <br /> Application is hereby made to tomplete In Triplicate) <br /> and/or install 9 <br /> he San Joaquin Local Health District for a permit to construcr,. <br /> the work herein described. This application Is made in compliance it ,. Jua <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local HewalhthSaDls rri <br /> JOB ADDRESS/LOCATION 17595 ,(/. ,7 . -_ � <br /> ,,/ CENSUS TRACT <br /> Owner's Name .-lDe-v,. - <br /> .. Phone <br /> Address <br /> C6ctractor's Name -�• ' 6 rT.µ r1 <br /> "`n c o License 11 n <br /> �---_ ��n f Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION / 7 DESTRUCTION <br /> PUMP INSTALLATION ;1l PNI•Q' REPAIR /% PUMP REPLACEMENT /_7 <br /> Other L/ — <br /> DISTANCE TO NEAREST: SEPTIC TANK -O � SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY - <br /> _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOI•fl:STIC WELL <br /> INTENDED USE PUBLIC DOMESTIC WELL <br /> TYPE OF WELL <br /> Iomestic/p CONSTRUCTION SPECIFI77 CATIONS <br /> Domestic/private Cable Tool Dia. of Well Excavation p <br /> Domestic/public Drilled Dia. Of Well Casing <br /> .i Irrigation Driven Gauge of Casing i Z — <br /> Cathodic Protection Gravel Pack Depth of Grout Seal j D <br /> Disposal -�- Rotary Type of Grout - <br /> - Other <br /> ..� Geophysical Other Information — <br /> 1 Surface Seal Installed B .- � <br /> PUMP INSTALLATION• Contractor <br /> Type of Pump <br /> c. <br /> _ <br /> PUMP REPLACEMENT• / <br /> lei <br /> • <br /> ------__ / State Work Done H.P. <br /> j' PUMP REPAIR: %% State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> S Describe Material and Procedure— Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local health Diatri'ct <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 Dibt:ict <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. <br /> PRIOR TO GROUTING AllD A FINAL INSPECTION. I WILL CALL FOR A GROUT INSPECfICN <br /> ( 5?CNED <br /> 2� TITLE, r,_ <br /> 'z. <br /> kL1.R,,W PLO REVERSE SIDE) _ <br /> M7 PHkSE I FOR DEPARTMENT USE ONLY <br /> APeLICATION ACCEPTED BY <br /> AUDITION.IL COMM'_NTE: � � �- `r DATE - <br /> "��`��... PILASE II GROUT INSPECTION _HAS • II/F"lJ.4I. INSPECTION <br /> i?:SPL'CT1UN BY DATE -- <br /> pp INSPECTION B , _ DATE ���y,..., <br /> is 1,126 F;c v. 1-74 3/76 <br />