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(41g-1 , SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.O FILE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-3� <br /> Q THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z- <br /> F. C.,te Cir/40 (Complete In Triplicate) . /77—`f`?0__0 <br /> Application is hereby made to the San Joaquin Local Health District. for a permit gto 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 F /,� t �r,, ,:n, a �, ,�r CENSUS TRACT <br /> ..�, f <br /> Owner's Name . .�, ._ Phone <br /> Address /X'/ �� r ,� r City .� ^_ <br /> Contractor's Name c,c License # / .� Phone 2, 7g.Z& <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN '/-7 RECONDITION /_7 DESTRUCTION /_7 <br /> i <br /> PUMP INSTALLATION / / PUMP REPAIR/�-(7 PUMP REPLACEMENT f7 <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 <br /> _>4, Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 Z_f _ � • <br /> Type of Pump `7 a-4- . _ H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP 'REPAIR: / State Work Done <br /> AES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II 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 GROUTING AND A FINAL ON, <br /> SIGNED TITLE �^ <br /> DRAW PLOT P ON REVERSE SIDE <br /> R 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 .C_ d DATE �•-?-7� <br /> !i_/.75_2M_ <br /> E H 1426 Rev. 1-74 _ <br />