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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOBi OFFICE,—VSE: 1601 E. Hazelton Ave. , Stockton, .Calif. . <br /> Telephone: (209) 466-6781 /7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No*. <br /> ., / - 1 <br /> THIS PERMIT EXPIRES 1 YEAR-iFROM DATE ISSUED Date Issued 7R70 <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:' 186 and tjie Rules andRe <br /> gnlatians= ofrhe San Joaquin Local Health District. <br /> JOB ADIDRES.S/LOCATION . «.:. =. ,: ., CENSUS TRACT <br /> Owc3er°s Name Ile Al <br /> _ Phone 773 /g©^ <br /> d <br /> Address - 7'ltl3 .. city <br /> Contractor's Name . 16&0 LicenPhone� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other I f <br /> DISTANCE TO NEAREST: SEPTIC TANK ) G SEWER LINES )"�Q4 PIT PRIVY _ <br />! SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. -40 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. .of Well Excavation <br /> __z <br /> .Domestic/private Drilled Dia. of Well Casing 2E ®' <br /> Domestic/public Driven Gauge of Casing _ JQ�-Z <br /> 'Irriga'tion y Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout .:j&' Ale <br /> i Disposal Other Other Information <br /> Geophysical.. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor": _ 11-16c) <br /> 'type -of Pump - ;57,v.6 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> :REPAIR: Done <br /> .2gS'TRUCTION 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 '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 �, DATE <br /> ADDITIONAL COMMENTS': fi W� <br /> PHASE II;�,GROUT`TNSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ka �? t .t' `` 'DATE •"INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />