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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE FICE USE; 1601 E. Hazelton Ave. ; ,Stockton, Calif. <br /> 209: <br /> Tele hone466-6781 <br /> P ( ) <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6�S`9tar�J <br /> ,p <br /> THISPERMIT EXPIRES 1,YEAR FROM DATE ISSUED Date Issued <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 /> County Ordinance No. 1862 and the Wes and --Regulations -of the San Joaquin Local Health District <br /> '2 <br /> .FOB ADDRESS/LOCATION CENSUS TRACT �z <br /> Owner's Na _ �5 .Phone <br /> Address (� `rlxsr�` 917�' City <br /> Contractor's NameLicense � �3hone �9�� f G <br /> -- - --- i <br /> .•- s��- <br /> TYPE OF WORK-(Check) : NEW WELL DEEPEN/ / RECANDITTON /� DESTRUCTION /-7 ;} <br /> ' PUMP INSTALLATION ') PUMP REPAIR J / REPIA EMEN�wT�7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER pD <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL : <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFY T NS <br /> industrial Cable Tool Dia. of Well Excavation 6� <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. �- 779 <br /> Type of Pump.. st<'T" 6-4 H.P. 77 <br /> PUMP REPLACEMENT: . / / State Work Done 7 <br /> PUMP_REPAIR: J.:/ State`Work Done <br /> t — <br /> ,DESTRUCTION OF WELL: Well Diameter 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 DATS- <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-beat of. my.knowledge and belief. I WILL CALL FOR A. GROUT INSPECTION.- <br /> PRIOR TO GROUTING AND:`A FINAL INSPECTION, <br /> SIGNED 7-yi:. ° TITLE <br /> + D W4M PLAN ON REVERSE SID <br /> rPART T�2= <br /> USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT / DATE O 23 �76 <br /> ADDITIONAL -COMMErTTS: _.� % I <br /> . _a. P INSPECTION PHAS NAIAXNSPECTION <br /> INSPECTION'=BY DATE INSPECTION BY DATE <br /> �. <br /> M. <br /> E41426 1-74 <br />