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�1601 <br /> SAN JOAQUIN LOCALHEALTH DISTRICT <br /> OFOFFICE USE E. Hazelton Ave. , ,Stockton, Calif. <br /> ' <br /> Telephone : 11 (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2;,,_ <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued -�7-7� <br /> (Complete In Triplicate) <br /> Application is iereby 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 /> i County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,"] �,/,(,C/ S CENSUS TRACT <br /> Owner's Name /�L r A N Phone Y1I` 913' ' <br /> Address ----- 1 L �� c� r_'La�� �rJ City <br /> Contractor's Name - ^EauJ1 j3 ''Q License .# 7GZ6,2 Phone,��z--5_,51 <br /> A % <br /> TYPE OF 'WORK (Check) : NEW WELL & DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /% PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> ' DISTANCE TO NEAREST: . SEPTIC TANK SEWER LINES PIT PRIVY <br /> "SEWAGE1DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE -- PRIVATEiDOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool ;+ Dia. of Well Excavation �� 1 <br /> Domestic/private Drilled_': + Dia, of Well Casing <br /> Domestic/public Driven ;tGauge of Casing <br /> Irrigation % Gravel Pack; _J: Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> !^ Disposal Other Other Information <br /> _ - Geophysical ; ` Surface Seal Installed By:_07"fj_�fM <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. <br /> PUMP'REPLACEMENT: /_7 State Work Done <br /> E PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION 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 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�GROUT.I.NG AND A, FINAL INSPECTION. _ <br /> SIGNED �:S _ r S[,.., .i TITLE <br /> `(DIMW PLOT PLAN ON .REVERSE SIDE) <br /> ' v FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �7 ? <br /> ADDITIONAL COMMENTS: <br /> PHASE ,II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE =9' ' � INSPECTION BY DATE ,r <br /> 1177• 2M <br /> E H 1426 Rev. 1-74 <br /> . . <br />