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4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F06 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 8 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Tssued �] <br /> (Complete In Triplicate) <br /> Application is hereby made to <br /> 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 /> S J. l� z �&V L_t9 US TRACT <br /> JOB ADDRESS/LOCATION/�� � .•.� ���/`�C1A��{� � � � <br /> Owner's NamePhonedeal <br /> �209� <br /> i <br /> Address Elk 22/ !%ir ave C4fi7C 9sz� City <br /> License # Phone <br /> Contractor s Name <br /> _ <br /> TYPE OF WORK (Check); NEW WELL . DEEPEN /_7 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / f PUMP REPAIR'/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: -SEPTICITANK 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 SPECIFIC TIONS <br /> Industrial F Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation .! Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type.of Pump H.P. <br /> PUMP REPLACEMENT: . /—/ -State Work Done <br /> PUMP REPAI-R-: tate�WorkYDone <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth :aa <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 workIon 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 FIUL INSPE ION. <br /> SIGNED TITLE .,..�� a�e� <br /> D W. PLAN 'ON REVERSE SIDEr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: �. <br /> PHASE II GROUT}INSPECTION PHASE III FINAL INSPECTION . <br /> ' INSPECTION BY DATE INSPECTION BY DATE //-7,0-77 <br /> 3/76 2M <br /> E H 1426 Rev, 1-74 r .. <br />