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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> !� Telephone: (209) 466-6781 <br /> f I PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k II <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1>-aJ-7G <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 Rules and Regulations of the San Joaquin Local Health District. <br />° JOBS ADDRESS/LOCATION (� �c F N r �GIc�oM CENSUS TRACT <br /> Owner's Name - - f' l Q�rC' Phone <br /> k Address -- ---.5 Q t"'r C� . ._ .,..,..,__ City <br /> Contractor-'s Name �(�� Cc�4, le License PS Y9 77 Phone <br /> j TYPE OF WORK (Check) : NEW WELL '_Ig DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> I PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK > SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT Z>4QO OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation f4 <br /> -Domestic/private gilled Dia. of Well Casing l __ <br /> II Domestic/public Driven Gauge of Casing _ / a LA <br /> 11' Irrigation Gravel, Pack Depth of Grout Seal <br /> .11 Cathodic Protection `1 Rotary. Type of Groutcanda� r <br /> ,I1 Disposal Other Other Information w <br /> J1 Geophysical Surface Seal. Installed By: <br /> I� <br /> PUMP INSTALLATION: Contractor F' / (G a�a <br /> Type of Pump 2 q H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mater"ial-and Procedure <br /> I hereby agree to comply with all laws and regulations of the-San- Joaquin Local Health District <br /> an 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' ANP.-A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW FL T FLAN 'ON REVERSE SIDE) 'T ' <br /> ��. FOR 10EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE 12 3a7r INSPECTION BYDATE -51 <br /> 3/76 2m <br /> ` �E H 1426 Rev. 1-74 -. - � --- <br />