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I UJ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _.� p <br /> 71;-3070` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) / �/- �2_3v-r <br /> ' Application is hereby made to the San Joaquin Local Health District for a perzit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> 4 County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> LO �` �y j6#4 <br /> JOB ADDRESS/LOCA I CENSUS TRACT <br /> Owner's Name Phone <br /> t Address �� A � OE.6 <br /> City <br /> Contractor's Name L f U � License e hone */ <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN '/ / RECONDITION /W7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR- /—/ PUMP REPLACEMENT /_7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEP�GE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLA�" "_hBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA77ONS (}� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 3 Gravel Pack Depth of Grout`Se `" _ <br /> Cathodic Protection_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> i Type 'of Pump H.P. <br /> PUMP REPLACEMENT: / / 'State Work Done <br /> PUMP .REPAIR: ® � <br /> State Work D nd'e <br /> DESTRUCTION OF WELL: Wel Diameter A pr ima th <br /> De�ribe Mate" ia1 5ind Proced re <br /> Y L <br /> I hereby agree to comply with all la d 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 /> k WELL DRILLERS REPORT of the well and notify there 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. 'Al SIGNED TITLE <br /> D W PZ T PLAN ;ON REVERSE SIDE) <br /> p <br /> PHASE I 29LDEPARTNT USE ONLY <br /> _ <br /> APPLICATION ACCEP ZSAOVCc_ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S /FINAL INSPECTION <br /> INSPECTION BY . ,�: � DATE -7 INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />