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SAN JOAQUIN LOCAL HEALTH- DISTRICT z9.lLt1 <br /> F ; OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. GSLxo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,-Z-2-9--29 <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. 1862 and, the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOCATION ��� CENSUS TRACT <br /> C T <br /> Owner's Name °� Phone j <br /> Address -9c -City <br /> Contractor's Name J-° LicenseY!e Phone <br /> ACti <br /> TYPE OF WORK (Check) : NEW WELL '/ J DEEPE / CON DESTRUCTION 17 r <br /> PUMP INSTALLAT ON /' / IR / / PUMP PL CEMEN /� <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK S,WEP4 LINES PIT PRIVY <br /> SEWAGE DISPOSAL IFIELI CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRI k_ O_MESTIC WELL PUBLIC-DOMESTIC WELL <br /> INTENDED USE .' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable oq Dia. of Well Excavation <br /> -- <br /> Domestic/private Drilled`' - Dia.. of Well Casing <br /> Domestic/public Dr' YGauge of Casing- _ <br /> Q , <br /> ck <br /> Cathodic Protectio3 <br /> Rotary Type of Grout <br /> Disposal Other Other Information <br /> 'Geophysical Surface Seal. Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP .REPAIR: J / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and- Procedure i <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 OfL my..knowledge and belief. I WILL C FOR A GROUT INSPECTI N ; <br /> PRIOR- TO G UTING A FI AL S CTION. <br /> SIGNED TITLE' <br /> DRAW POT PIAN ON RE E2S E SI <br /> .- FOR DEPARTMENT USE ONLY , <br /> PHASE I et0 <br /> APPLICATION ACCEPTED BY / ' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />