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L <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICx �I01) <br /> FOR OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: {209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74 ��p <br /> THIS PRRMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -76 <br /> �-ate <br /> (Complete In Triplicate) <br /> Applicition 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 Joaquinl, <br /> County 'Ordinance`No' . 1862. and the Rules and Regulations of' the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION` CENSUS TRACT <br /> t <br /> Owner's Name ;�� '. } • Phone <br /> Address - M-G. City , <br /> i <br /> Contractor's Name License #f �' Phone .2j <br /> TYPE OF WORK XCheck)% NEW WELL -/? DEEPEN /_7 RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATIONf7 PUMP REPAIR /77 PUMP REPLACEMENT /7 <br /> . Other / / <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK` SEWER LINES PIT PRIVY I. <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 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 Other Other Information " <br /> - Geophysical Surface Seal Installed 'E j <br /> PUMP INSTALLATION: Contractor <br /> l <br /> .ype .of Pump H.P. <br /> i <br /> PUMP REPLACEMENT. .. / / State Work Done j <br /> PUMP ,REPAIR: / State Work Donee <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II' 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 TITLEr,� h� <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOA 74EP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED-,,,- DATE 2-5-76 <br /> ADDITIONAL COMMENTS: <br /> PHASE -II GROUT INSPECTION PHAS I F NAL INSPECTION <br /> INSPECTION BY DATE, INSPECTION BY DATE tY <br /> E ii 1426 Rev. 1-74 l h/75 2M <br />