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a z� SAN JOAQUIN LOCAL HEAfTH DISTRICT <br /> FOSS;*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �4J <br /> k <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 77 <br /> J7 <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 /> f County Ordinance No. 1662 and the Mules and Regulations ofa San -J a Local Health District. <br /> s� s ` . <br /> i JOB ADDRESS/LOCATION -sk C.t9'144� I �o[ CENSUS TRACT . <br /> Owner's Name f Phone ' <br /> Address <br /> ` G City . . <br />; Contractor's Name License # . d Phone - Q <br /> _ �/3 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN ,/_7 RECONDITION /j DESTRUCTION /� Y . <br /> PUMP INSTALLATION PUMP REPAIR/� PUMP REPLACEMENT %7 <br /> Other /% <br />' DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEXPRIVATE DOMESTIC WELL" PUBLICDOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation .41 <br /> I _ X Domestic/private Drilled .. <br /> ___ Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection Rotary Type of Grout , A Y=? W <br /> Disposal- Other Other Information """"""' "' <br /> Geophysical 41 13r4 <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: j/77 State Work Done <br /> PUMP_'REPAIR: ././=/-. :, tate_Work,Done' <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 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 .weli. in.use-. . The above ' <br /> information is true tobest -of my.knowledge and belief. I WILL CALL 'FOR A 'GROUT INSPECTION <br /> PRIOR TO R TING F NAL i.NSPECTION. <br /> SIGNED4 Z441 &d, TITLE LU/tO� <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPE ION PHAS II][ AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 426 Rev. 1-74 - 1./?Cf ou <br />