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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: U401601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 1p s-aA <br /> THIS PERMIT 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 Rules and Re_gu1 tionsGof thean Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> J CENSUS TRACT <br /> Owner's Name X ROBERT H. (BUDGE) BROWN Phone 823-5451 <br /> Address 874 EAST WOODWARD AVE. City MANTECA <br /> Contractor's Namel' A & B .ELECTRIC License Phone <br /> . .---....._ *�.—._ter."'.=-_c-_"�---�---,�-'-� -s�'*. --.�ws--�--s'.�.'c-.a-�--�... ��.:.�' -_<'-�s�--'�_-a-c�=� �.-- „�<•_ ,_ _ _ <br /> i� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/_/ RECONDITIONDESTRUCTION /_7 <br /> /_/ <br /> PUMP INSTALLATION <br /> Other , PUMP REPAIR/ / : PUMP REPLACEMENT /� <br /> — <br /> — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .r <br /> PROPERTY LINE - PRIVATE DOMESTIC' WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout f <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contra ctorg CTRIC _ <br /> Type of Pump xstt r,- E H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL` Well Diameter Approximate Depth <br /> t <br /> Describe Material and Procedure <br /> I hereby agree to comply. with all laws and regulations of the San Joaquin Local Health,District f <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 d <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true to the t of. my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GROUT AND A IN ION. <br /> SIGNED TITLE <br /> 77-7� --------- <br /> (DRAWT <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 49 Z, 'l <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASE / INAL NSPECTION <br /> INSPECTION BY . DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />