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FO9 SAN JOAQUIN LOCAL- ALTH. DISTRICT <br /> R OFFICE USE: r 1601 E. Hazelton Ave. , Stockton, Cali + <br /> v <br /> Telephone: (209) 466-6783 . i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7h 57 ' <br /> THIS FERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-3 <br /> -76 <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/LOCATIONS CENSUS TRACT ' 1 <br /> Owner's NamePhone <br /> Address �5:�as- �{���� City���� - <br /> Contractor's Name ` t .1.[�J, �►lliLL License �� � Phone -/03 i <br /> { �-`- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN/ J RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <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 Jet <br /> 4�--bomestic/private /—Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing --- <br /> Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection . 4�—Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . " / / ..S tate Work Doxie <br /> T <br /> -��- <br /> PUMP .REPAIR: / /� State Work Done <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 we ff' 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. V WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G46UTING AND-,,A F AL IN ECTIO . <br /> SIGNED ) ' t TITLE L� 4'J <br /> DRAW PLOT LAN 'ON!RE RSE SIDE} <br /> DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY ,, DATE? -/ <br /> ADDITIONAL COMMENTS; <br /> P IkKRT INSPECTI N PHASE III/ NAL JNSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE - 7� <br /> 6� C � -3/76 2M <br /> E H 1426`'% Rev. 1-74 <br />