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SAN JOAQUIN LOCAL HEALTH ISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> :`. Telephone: (209) 46''64781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. s <br /> I� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued � 3 <br /> (Complete In Triplicate) / = )3d--0� <br /> Application is her mide tai the San Joaquin Local, Health Districtfar a permit to construct <br /> This application is made in compliance with San Joaquin <br /> and/or install the work''herein described. in <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1� 7t LP � �=cn: c= ,2;J <br /> .JOB ADDRESS%LQCATION� A ,,,� t .� ' <br /> NSUS TRACT <br /> Owner's Name n _ KA <br /> Address Phone ' d. Z_ ; <br /> City ,-, _V <br /> Contractor's Name <br /> License # 11g941. Phone <br /> TYPE OF WORK-..(Check) .,,, 'NEW.-WELL /7 DEEPEN '/? RECONDITION /_� DESTRUCTION <br /> ,. PUMP INS'TAI,LATION / / PUMP REPAIR -/? PUMP REPLACEMEN' /� { <br /> Other /.`./ ,� — <br /> DISTANCE TO;NEAREST: SEPTIC TANK <br /> SEWER: LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ` ` CESSPOOL/SEEPAGE PIT OTHER <br /> f # <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i <br /> Industrial `" t: j CONSTRUCTION SPECIFICATIONS <br /> Cable `Tool Dia. of Well Excavation <br /> Domestic/private- v ql — Drilled Dia. of Well Casing <br />_ Domestic/public Driven i <br /> Irrigation., Gauge of Casing <br /> ;Gravel Pack - Depth�nf-Grout Seal <br /> Cathodic Rrotectiofi�rr- a ' : 4otar <br /> Disposal y '�: -._. ., .TY-Pe of Grout <br /> Other Other Information 'Geophysical Surface Seal Installed B 4.1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. i <br /> PUMP REPLACEMENT: 1 ` <br /> . .. / / State Work Done <br /> PUMP ,REPAIR: ti <br /> State Work Done } <br />)ES;TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure APproximat 'Depth, <br /> C hereby.agree to .com 1 <br /> P y-wi-th-a-11 laws• and- regulations -of^the San Joaquin Local Health District i <br /> Ind the State of California pertaining to or regulating°.well."construction. _ _Withln_.FIk"TEEN.DAYS f <br /> after completLoii„`of my work�on a new well, I will furnish the San Joaquin Local Health District a <br /> JELL 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 FORA GROUT INSPECTION i <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> iIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br /> h <br /> PPLI A ION ACCEPTED BY � j <br /> DDITIONAL COMMENTS: DATE - 7 <br /> I <br /> �F <br /> PHASE II GROUT INSPECTION _ 4 <br /> NSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTION BY DATE/p <br /> .y. i <br /> E H 1426 Rev. 1--74 ii .; ` <br />