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C�0 /AOn SAFFMQUIN LOCAL HEALTH DISTRICT <br /> FOI;.OF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74L3In <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquini <br /> County Ordinance No. 186 and the Rules Ind Regulations of theSa Joaquin Local Health District. <br /> 4 SA Sep vrw <br /> JOB ADDRESS/LOCATION ltd s% � a ,.a�., e 3 U, 1a C Avjaj* _,9"AhWCENSUS TRACT -� <br /> i <br /> Owner's Name Phone ' <br /> i <br /> Address ..f� 4 .2/6 City d - <br /> Contractor's Name C,z � License # / hone �'6)1--74 74 <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN -/7 RECONDITION !-T DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR j�g7 PUMP REPLACEMENT % 7 <br /> Other /J . . . <br /> DISTANCE' TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI'S OTHER <br /> If PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing - <br /> Irrigation Gravel, Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal T Other Other Information. <br /> Geophysical Surface Seal Installed 'By. <br /> PUMP INSTALLATION: Contractorc60 v <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT:, j_/ State Work Done _ <br /> PUMP :REPAIR: State Work Done�,,,f�/r_., 1��. ,r,-✓_ _Ul�f� <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 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 owled a an belief. I WILL CALL FOR A GROUT• INSPECTION <br /> PRIOR TO GROUTING AND,A FINAL IUpE N. <br /> SIGNED ,. ITTLE <br /> {MF 1PL-01f'PLANON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> 1 PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION By DATEtf b 9 <br /> R u 7G9A ate.. 1_7/. •� � h/77 2M <br />