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SAN JOAQUIN LOCAL HEALTH DISTRICT #,til <br /> ICfF OFsICE''L�SE: D 11601 E. Hazelton Ave. , Stockton, Calif. 2-� Ose <br /> PA4t yip�'.. Telephone: (209) ' 466-6781 r �7 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT p <br /> No. <br /> /-C?_7g <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ate Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 /> County Ordinance No. 1862 and the Rules and Regulati <br /> o <br /> ns of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / GJc /�1' ON "�+v - ENSUS TRACT <br /> Owner's Name / e ���G� k <br /> Phone <br /> Address rAlAev tvz <br /> City <br /> Contractor's Name 1*V1V,1,y04 cense Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN '/% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> jg6 SEWER LINES,��-7` PIT PRIVY € y' <br /> SEWAGE DISPOSAL FIELD -- CESSPOOL/SEEPAGE PIT-~.-OTHER - <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOME 7'IC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSf <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. o€ Well Casing �/ <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation 44 Gravel Rack Depth of Grout Seal <br /> Dshodic osal Protection _ Rotary Type of Grout <br /> � P 1, Other Other Information s D G✓ <br /> Geophysica3 `+t kr Surface Seal Installed <br /> PUMP IJS <br /> TALLATION: Contractor - <br /> Type of Pump H.P. <br /> l s-"= <br /> PUMP REPLACEMENT: /} Stat a Work.;Dame <br /> PUMP REPAIR: / / State Work Done , <br />]ESJRUGITION OF WELL: Well Diameter Approximate Depth <br /> 'r <br /> Describe MaterialTand Procedure <br /> I hereby agree to comply with all laws-and regulations of the San Joaquin Local Health District, t <br /> and the State ofornia pertaining tq or regulating well ''construction. Within FIFTEEN DAYS, <br /> after c'omplet' of y work on a new well;'\I will furnish the San Joaquin Local Health District: a <br /> aELL DRILLE POR o e w 1 and notify them before putting the -well in use. The above <br /> Lnformati . is- r-,ue o he es/i of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION" <br />'R10RIN ECT ION. <br /> 3IGNED ` TITLE ` <br /> ¢. } / . <br /> (DRAFT PLOT PLAN ON REVERSE SIDE) <br />'RASE I <br /> *FOR DEPARTMENT USE ONLY <br /> Ab r <br /> 1 <br /> - +' <br /> LPPLICATION ACCEPTED BY r Es,TE <br /> PHASE II GROUT INSPECTION PHASE III/FIj4AL INSPECTIONI <br />[NSPECTION BY DATE INSPECTION BY DATE /—/0- <br /> E <br /> = Q-E H 1426 Rev. 1-74 <br />