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SAN JOAQUTN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton,Ave. , Stockton., Calif. � <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �4/ 1 <br /> 3 76r66ip <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f3a 76 <br /> (Complete In. Ttiplicate) <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 /> k <br /> JOB ADDRESS/LOCATION "� '� ENSUE TRACT <br /> Owner's Name 06, rt il A ac. tf ' Phone <br /> Address .. City <br /> Contractor's Name Tin 1" S -�� License hone <br /> 3 <br /> TYPE OF,WORK (Check) : NEW WELL DEEPEN & RECONDITION /_7 DESTRUCTION IV <br /> PUMP INSTICCLATION PUMP REPAIR -/ / PUMP REPLACEMEN /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT,PRIVY �- <br /> SEWAGE DISP05�' IELD C�/SEEPAGE PIT f00 ''OTHER <br /> PROPERTY LINB74fRIVATE DOMESTIC WELL " PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation Z /Z <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casirig ae. v\ f <br /> Irrigation ; Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection Rotary _ -Type of Grout. <br /> Disposal Other Other Information ' <br /> Geophysical s Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.}P. <br /> PUMP REPLACEMENT: / / State Work,Done <br /> PUMP '.REPAIR: `/ / :State Work'Done: 'V <br /> DESTRUCTION OF WELL: Well. Diameter tr •q�' " Approximate Depth <br /> -. Describe Material and Procedure Z <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 donstruction. 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 /> SIGNEDE / <br /> (D PLO REVERSE SIDE <br /> I. FOR DEPARTMENT USE ONLY <br /> PHASE I F ,76 <br /> . <br /> APPLICATION ACCEPTED BY DATE : �j fit' <br /> ADDITIONAL COMMENTS: <br /> PHASE Ij GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY _� DATE !E•/3 INSPECTION BY <br /> t E H 1426 Rev. 1-74 �, _ _ 4/75 2M � <br />