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-Ole SAN JOAQUIN LOCAL HEALTH- DISTRICT " <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> t Telephone: (2.09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s -7 <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 /> 4 County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LXENSUS TRACT <br /> I . <br /> Owner's Name f Q G L�' Phone <br />` Address 1 City <br /> i <br /> 01 <br /> Contractor's Name4License 4t,9 z/ET gJ7 Phone <br /> a� <br /> TYPE OF WORK (Check) : NEW WELL/!fi DEEPEN / "/ RECONDITION /_/ DESTRUCTION /- <br /> ' PUMP INSTALLATION- / PUMP REPAIR '/. / PUMP REPLACEMENT <br /> Other.1/ / a yz, �1. . '. <br /> DISTANCE TO NEAREST: SEPTIC TANK 5­406 SEWER LINES'" �;' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL V <br /> INTENDED USE TYPE OF WELL V, CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Z__--Cable Tool Dia. ;of Well Excavation 2 <br /> Domestic/private t Drilled" Dia `-,uf-Well Casing <br /> Domestic/public I Driven �* Gauge of Casing z Q <br /> "1"`Gravel`Pack -Depth of Grout-Seal <br /> Cathodic Protection j Rotary- ` Type of Grout <br /> Disposal Other, Other Information <br /> Geophysical Surface Seal Installed B : <br /> k PUMP INSTALLATION: Contractor _ <br /> Type ;of'Pump 4.0 .,...,,, .,..—H.P <br /> PUMP REPLACEMENT: � / / State,Work Done <br /> PUMP .REPAIR: / / State Work-Done <br /> DE5 TRUCTION OF WELL: Well Diameter r...,�._.� 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 A GROUT INSPECTION <br /> PRIOR TO GRO Tla2 AND A FINALS INSP ON. <br /> SIGNEDTITLE . <br /> 1 (�f 11DRAW- PLOT PLAN ON RE ERSE �SIDE)^ <br /> FOR DEPARTMENT USE ONLY;:., <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY _ - ..:�� DATE (25 ,;-p- 7 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT -INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE, INSPECTION BY TE <br /> E H 1426 Rev.. 1-74 ' 9/76 2M� <br />