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^ i <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. ,, Stockton, Calif. <br /> Telephone: -(209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION, OR PUMP PERMIT Permit No. 7S-1L�S ! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED Date Issued <br /> (Complete -In Triplicate) <br /> Application is hereby made tolthe .San Joaquin Local HealthDistrictfor 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/LOCATION E CENSUS TRACT <br /> Owner's Name �� L /� Phone <br /> Address City /r`'iexl _-- <br /> i� ; <br /> g,. Coiifra�cfGr�'s{,iCenSE <br /> Contractor's Name � +�` '" License �� p�,,..2��66�hOne _ �?O } <br /> i <br />-.T=YPE DEEPEN /7/� RECONDITION_ / ./-'---DES-T-RUCTION%------- 4 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Lam► <br /> Other <br /> DISTANCE TO 'NEAREST: SEP-TIC/TANK SEWER LINES PIT PRIVY jL <br /> SEWAGE 'AISPOSAL;FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1. <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Tndustrial /Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> f Domestic/public Driven Gauge of Casing <br /> Irrigation , r4 Gravel Pack , / Depth of Grout Seal <br /> Cathodic Protection. .,-' Rotary Type of Grout <br /> I Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump - H.P. <br /> t <br /> PUMP REPLACEMENT: State Work Done 6,L L(. Ul7 5 LLi °+l /b' ►, . //-//� �S GG� <br /> PUMP .REPAIR': / / State Work Done f <br /> '- �A roximate-De th � <br /> i DE-S-TRUC_ TION-OF WELL---W '11"Diameter 6 pp �P <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 GROUTIN FINAL INSPECTION. <br /> SIGNE ' -;,' TITLE177 <br /> y DRAW PV' T PLAN ON REVERSE SIDE) <br /> ` FOR EPARTMENT USE ONLY <br /> PHASE I 'i' <br /> APPLICATION ACCEPTED BYE DATE <br /> ADDITIONAL COMMENTS: t± <br /> PHASE :II:-GROUT INSPECTION PHASE -II;/FINAL INSPECTION p ' <br /> INSPECTION BY DATE �/1- INSPECTION B DATE,, A <br /> 3/76 2M <br /> � r E H 1426 Rev. I-74 _ <br />