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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -3If <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -S-3d- 77 <br /> (Complete In Triplicate) ' ��k5 -I3o -E1� <br /> Application is $ereby 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. 1$62 and' the Rules and Regulations of the San JoagAin Local Mealh District <br /> JOE ADDRESS/LOCATION174) <br /> 1 o d N CENSUS TRACT <br /> Owner-is Name Phone 0-2 <br /> Address . City ! A <br /> ' Contractor's" Name m icense # Q/b3Phone2-o39 <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION &7/' PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other / / /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK —SEWER LINES ... PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD"- 4. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> INTENDED'USE, TYPE OF WELL CONSTRUCTION SPECIFICATIONS" <br /> Industrial ` , Cable Tool Dia of Well- Excavation v, <br /> Domestic/privat'e .ti Drilled Dia. of- Well Casing It <br /> 01 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation , Gravel Pack " Depth of Grout Seal d -- <br /> F %Cathodic Protection Y '*._ Rotary Type of Grout "' <br /> Disposal Other Other Infos tion _ L-- _ <br /> 'Geophysical ,�� Surf ace Seal Installed By: <br /> P_U4 INSTALLATION: Contractor <br /> -- i Type of Pump C, H.P. <br /> k4REPLACEMENT: / /Ar State Work Donees w <br /> � k r <br /> PUMP .REPAIR: / / State Work Done 1 <br /> DEStRUCTION 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 bistrict <br /> and the State of California pertaining to or regulating we11 ''construction: Within FIFTEEN DAYS <br /> after completion of my work on. a new well, I will furnishY_the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the welfl in use'. The above <br /> informa n is true tMAVU�\�_PAUTION.of. my knowledge and belief. I WILL CALL' FQR A GROUT INSPECTION <br /> PRIOR TO TING AND <br /> SIGNED TITLE (?_O c`rVl��_q� <br /> i 4 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR PEPARTMENT USE ONLY <br /> PHASE I F. _ ... - . <br /> APPI ICATION ACCEPTED "BY DATE 30 <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION M PHASE IJTWFINAL.,INSPECTION <br /> ! INSPECTION BY DATE /�' -INSPECTION BY DATE,--a �� 77 <br /> '4E H 1426 Rev. 1-74 <br />