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SAN;J:OAQUIN LOCAL HEALTH DISTRICT j <br /> 9R,.-OFFICE USE: 1601 'E: .Hazelton Ave. , Stockton, Calif. <br />-ter Telephone: (209) 466=6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-/34I/d.�l <br /> �• <br /> THIS PERMIT EXPIRESI YEAR-FROM DATE -ISSUED Date Issued <br /> . .(Complete In-Triplicate) <br /> Application is hereby made to the San Joaquin,Local Health District for a conct <br /> permit to atx�ei <br /> and/or install the work herein° described:. This application. is made in compliance with San Joaquin ` <br /> County Ordinance No. 18G2 and the Rules and Re <br /> $ulationa of: the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .' <br /> CENSUS TRACT <br /> ,Owner t s Name t� b/ 4 Phone <br /> Address <br /> City <br /> Contractor'syName License # <br /> S' 7` Phone <br /> TYPE OF WORK (Check): NEW WELL & DEEPEN-177 RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION L_7, PUMP REPAIR L-7—Pump REPLACEMENT L7 <br /> Other /? <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD mow . CESS OP OL/SEEPAGE PIT' <br /> � <br /> PROPERTY LINE - PRIVATE MESTIC WELL PUBLIC DOMESTIC WELL <br /> E L� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � <br /> K Cable Tool Dia, of Well Excavation <br /> 7— Domestic/private Drilled Die. of Well Casing �• <br /> Domestic/public _ Driven:" Gauge of Casing <br /> "7X Irrigation g Irri Gravel Pack Depth of Grout Seal <br /> . Cathodic Protection. Rotarya of Grout <br /> —Disposal <br /> Geophysical �r Other, � <br /> Other Information <br /> "• '.''��-.... �`_' 'r,— "- <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor -- - <br /> Type of Pump H.P. 3: .. <br />'PUMP REPLACEMENT: L7/,�;,,/ State Work Done20,%,, <br /> PUMP :REPAIR:rJ L7 State Work Done F <br />&TRUCTION OF WELL: " Well Diameter <br /> _ Describe Material and Procedure Approximate Depth <br /> i� <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..well in use.. The above <br /> information is true to the.bes of. my owledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING FINAL of <br /> ON. <br /> SIGNED <br /> TITLE � . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE T FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 3/ r <br /> PHASE II.GROUT I PECTION ' <br /> INSPECTION BY ` ` PHAS I INAL INSPEC IO <br /> DATE <br /> INSPECTION BY DATE <br /> �E H�1,426YAev. 1-74. , �• ,, Y`` <br /> rr' r <br /> '7" <br />