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SAN JOAQUIN,LOCAL H A TH. DISTRICT <br /> FOR OFFICE USE: IrS01 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone : (209) 466-67$1 <br /> ADPL ON FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 44 <br /> �► THIS PERMIT EXPIRES I. YEAR FROM DATE .ISSUED Date Issued <br /> (Complete 'In Triplicate) <br /> Application is hereby made to the San Joaq,uin.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 ADDRESS/LOCATION; OQ <br /> S TRACT <br /> Owner's Name . r , <br /> Phonecr <br /> ��yy .... <br /> Address92 <br /> C.� City <br /> Contractor's Namenr- <br /> LicensePhon { �, <br /> TYPE OF WORK (Check) : NEW, WELL DEEPEN /�/ RECONDITION DESTRUCTION DESTRUCTION /_7 <br /> . PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES ,- PIT PRIVY Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Well Excavation Z <br /> Domestic/private Drilled Dia. of Well Casing X 1T <br /> Domestic/publici Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 142 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / ./ State Work Done " <br /> PUMP REPAIR: / / State one <br /> - - �O �L.L � ..Gll_ �'`li Cit 1 C <br /> DESTRUCTION OF _WELL: 11 Diameter T Approximate Depth <br /> Describe Material and Procedure <br /> so_, /7 rG� <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Z__� DATE , 1 2— 76f <br /> ADDITIONAL COMMENTS: <br /> PHAph ,gI GROUT INSPECTIONPHAS / NAL INSPECTION <br /> INSPECTION BY DATE Q� 7� INSPECTION BY <br /> . E- H 1426 Rev. . 1/T4 jn2M <br />