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ire/ — <br /> Ile <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTFOOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-10-s3/0y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /off <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 an Re ulatio s of the San Joaquin Local Health District. <br /> /.,3'�0,� sic / � /2 s�-C,,.rf' <br /> JOB ADDRESS/LOCATIONZDLyaeas CENSUS TRACT <br /> � <br /> Owner's Name Phone .3 1p© <br /> Address _ f' <br /> City <br /> F. <br /> Contractors Name ri License /6 Phone 0 <br /> TYPE OF WORK (Check): NEW WELL 17 DEEPEN '/-7/-7 RECONDITION /7 DESTRUCTION /`7 <br /> ALY <br /> � a "r-PUMP-INSTLATION �C/ PUMP REPAIR /� PUMP REPLACEMENT %7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 (1 <br /> Industrial Cable Tool Dia. of Well Excavation �., . <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing x <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 By: <br /> PUMP INSTALLATION: Contractor <br /> .'.f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j/7 State Work Done <br /> -PUMP-:REPAIR: "' _- ,L-7 State Work Dotie <br /> ES.TRUCTION 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 knowledge and belief. I WILL CALL FOR' GROUT INSPECTION <br /> PRIOR TO GROUTING AND FIN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION <br /> PHASE-_U.I4MLAL,,INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY/ � DATE <br /> E H 1426 Rev. 1-74 1-74 IM <br />