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_ _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOF, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -..f . <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 11calth District for a permit to construct_ <br /> and/or :,nstall the work her^_in described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health DlotricC. <br /> JOA ADD:tESS/LOCATION 41 I ax( 1, Q L`//"// S /1 r R CENSUS TRACT <br /> Owner's Name ,N'4L21 _ �Q'1-1/W AA ��yy Phone <br /> Address <br /> Cortractor'a Name ;��-. �� r/� 1.�� �+w Licensees4 y �on�Y�L A._S •; <br /> s <br /> TYPE OF WORK (Cneck): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTIONf7 <br /> PUMP INSTALLATION Li. PUMP REPAIR /—] PUMP REPLAcEmENF LT <br /> Othar <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY ^ <br /> SEWAGE. DISPOS T. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P•20PZR7Y LINE - PRIVATE DOMESTIC WELL -- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE; OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool Dia. of Well Excavatio%, <br /> 1.2 <br /> kr�Dcmestic/private Drilled Dia. of Well Casini 9 \ <br /> Domestic/public Driven Gauge of Casing 47 <br /> i Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary Type of Grout <br /> Disposal Other Other Informati..a Q <br /> Geophysical Surface Seal Installed Bv: <br /> PIIMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMEIrT: L/ State Work Done <br /> ?U`:P .REP"IR: i i State ::ork Dont _ <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 Distr.'at <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN a'.YS <br /> after completion of my work on a new well, 1 will furnish the San Joaquin Local Health Distr_et <br /> WELL DRILLERS REPOET o. tiro wall and notify them before putting the well in use. The above <br /> information is true to the gest of n:y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR21'TINGtkND A I'i1z.,7.,dNSPECTION. <br /> SIGNED " - ►" TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DFPA_RTMENT USE ONLY <br /> PRASE I 1 <br /> DATE <br /> APPLICATION ACCEPTED BY1/ _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY l'•% DATE ' Zo <br /> ?; H 1426 Rev. 1-74 L/75 <br />