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- I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOF4 <br /> (OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> TelephoneA (209), 466-6781 LI—_ <br /> Y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S LC1 <br /> _THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �l'/3- Z <br /> v--- (Complete In Triplicate) O1 3 - 040 -qZ <br /> Application is hereby "ade 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB AWLOCATION.S S ;`/ /d�'1 ,/ L �T_ j ; (�r,�.. . CENSUS TRACT <br /> Owner's Name `. Ic Phone <br /> Address �� -� - 9�/ll i�/� d �� clAew City <br /> Ctractor'-a Name J License �7,��Phone ,9/32/o <br /> oinS'Z <br /> TYPE OF WORK (Check): NEW WELLZIDEEPEN /-7 RECONDITION /7 DESTRUCTION /.PUMP INSATION / PUMP REPAIR /� PUMP REPLACEMENT , . <br /> Other / 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES `� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CSSSPQ0L/SEE AGE PIT l O O f9THER N <br /> PROPERTY LINE PRIVATE DOMESTIC WELL _ tPUBLIC 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 a <br /> i Geophysical. ' Surface Seal Installed BY: <br /> j <br /> PUMP INSTALLATION: contractor , 14 . <br /> r Type of Pump A.P. <br /> 4 PUMP REPLACEMENT: / / State Work Done <br /> PUW- REPAIR: �� /_7State Work Done' - <br /> { RES- RUCTION 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 Califprnia pertaining to or regulating well const=uctio ;7`--Wi6An FIFTEEN DAYS <br /> after completion of mq� work on a new well., I will furnish;`the;1SAi Joaquin Local Health District a <br /> f WELL DRILLERS REPORT of the well and notify them before putting the. well in-use.. The above <br /> ' information is true 6the-best.of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND 'A FINAL INSPECTIO <br /> SIGNED ij� [ /1�—TITLES <br /> 41 W P OT ON REVERSE SIDE <br /> l FOR LIEPARTMENT USE ONLY � <br /> PHASE I I. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P II G UT INS CTION PHASE II FI AL INSPECTION <br /> INSPECTIONBY ATE . - �- INSPECTION BY DATE <br /> ,w <br /> I E H 1426 Rev. 1-74 1-74 2M <br />