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SAN JOAQUIN LOCAL HEALTH. DISTRICT — <br /> ROR�OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete InTriplicate) <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 /> JOB ADDRESS/LOCATION 31-74TI &j/ /J-® CENSUS TRACT <br /> Owner's Name Gig r p <br /> Phone d�3� 5l3 <br /> Address 7'6-.� (,{� <br /> City/ <br /> Contractor's Name(ol'��Z. License OR(lZ Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> F7 DEEPEN / / RECONDITION /_7 DESTRUCTION /_7PUMP INSTAT�,T,ATION � - PUMP PAIR / PUMp REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 11 <br /> Industrial Cable Tool Dia, of Well Excavation V <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 t , <br /> Geophysical .Surface Seal Installed B : V� <br /> PUMP INSTALLATION: Contractor ! <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> Q <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 DAYS <br /> after completion of my work on anew 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 C4J3L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL IN PECT <br /> ION <br /> . <br /> SIGNED TITLE L � ' <br /> W PL T PLAN RE ERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY� DATEX, 1/,_,/7z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS&jj1/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> E H 1426 Rev. 1-74 ' /76 <br />