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r <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. G ' <br /> Telephone: (209) ;466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued o <br /> " (Complete In Triplicate) Set A&v 1' 1?* 76-SS7 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 441a�-x—_a4 CENSUS TRACT <br /> Owner's Name LS��.r,�. Phone <br /> Address City <br /> Contractor's Nome �} -1 License # & Phone <br /> TYPE OF WORK (Check) : -,NEW WELLDEEPEN<"%/`'"RECONDITION / ./_ DESTRUCTION../� <br /> ;PUMP INSTALLATION /.. / PUMP REPAIR/ /`PUMP�:REPLACEMENT <br /> Other / / , <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK p SEWER LINES PIT PRIVY_ <br /> � 1 1SEWAGE DISPOSAL FIELD �d t CESSPOOL/SEEPAGEaP1T"_ ; JOTHER <br /> PROPERTY LINE 10PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL tCONSTRUCTION SPECIFICATIONS . <br /> Industrial 4 Cable Tool Dia. of Well Excavation <br /> Domestic/private '7 "i- Drilled Dia. .of Well ;Casing - <br /> Domestic/public s �Driveti.."" Gauge ,.of F_Casi'ng s <br /> Irrigation °�. - Gravel Pack Depth of Grout Seal - I <br /> Cathodic Protection`. Rotary Type of Grout ' <br /> Disposal f Other Other Information'-- <br /> Geophysical Surface Seal-Installed By:. <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: / /'may State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the at lifornia pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after comp tion of y work on4new1, I furnish the San Joaquin Local Health District a <br /> WELL DRIL RS REPO of the wei€ em efore putting the -well in use. The above <br /> informati n- is u to e' bes1 and belief. I WILL CALL FO GROUT INSPECTION <br /> PRIOR TO RbU FINAL 1 <br /> SIGNED �, ` TITLEJ <br /> W PLOT PLAN ON RE RS E S IDE <br /> ,l '4'FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY+ 0- DATE �Q <br /> ADDITIONAL �COMMNNTS:' <br /> PHASE II' GROUT INSPECTION PHAS III INAL INSPECTIO <br /> INSPECTION BY DATE/0 - �" 7.� INSPECTION BY DATE 7 <br /> 3/76 20, <br /> E H 1426 Rev. 1. 74 <br /> { <br />