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19t SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z /6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) M <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct E <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No.—J82 andt'ka Ru and Regulations of the San Joaquin Local Health District. <br /> 7UB6 76 A <br /> ADDREG S/LOCATION W19� &�GA zL A ACEN5U5 T�tACT J <br /> Owner's Name �1 /V' Phone J-� �J } <br /> i <br /> Address City ��' I <br /> Contractor's Name G _ U ,L License ��31P�gSf Phoned <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /Z7—'DEEPEN /_/ RECONDITION / / DESTRUCTION'/� - - - <br /> PUMP INSTALLATION /Z4--PUMP REPAIR / / PUMP REPLACEMENT f� <br /> Other.- / <br /> f 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK , ., EWER LINES PIT PRIVY „p <br /> SEWAGE DISPOSAL FIELD_��CE`SSPOOL/SEEPAGE PITX d-L_� OTHER kn <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL`'-LM PUBLIC DOMESTIC WELL Q <br /> 11_�.:INrTENDED USE } TYPE OT�VELL CONSTRUCTION SPECIFICATIONS <br /> Inaustrial-7 Cable Tool Dia. of Well Excavation <br /> i 4—Domestic/private Drilled 'Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /fir <br /> Irrigation t_- ; -.._.- Grav 1 ,.Pack _ ._Depth-„of Grout a1 Q <br /> Cathodic Protection otary Tyre of Grout a oar 'tF <br /> I Other Irriformation o <br /> Disposal Other k <br /> Geophysical .i rface Seal Installed B Marc <br /> PUMP INSTALLATION: Contractor <br /> Type�of_.Pump_ _ ___ H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .RE AIR: /_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> w <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 fuinish.<,thi 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 /> in aion is true to ..the�At <br /> - knowledge and belief. I WILL CALL FOR'A .GROUT INSPECTION <br /> PRIOR GROUTING AND` -PE .a, <br /> TITLE y <br /> SIGNED �h .---_. <br /> } PTT' PLAN 'ON REVERSE SIDE) <br /> r FOR DEPARTMENT USE ONLY A <br /> SEI <br /> f APPLI ACCEPTED BY DATE <br /> ADDITIONAL COPH SESII GROUT INSPECTION PHASE _1Tj1/FIINSPECTION <br /> INSPECTION BY DATE J M L3 ?� , INSPECTION BY DATE 1-7.1-79 <br /> 3/76 2M <br /> --74 <br /> E H ',1426 Rev. '1 --- _ - ` <br />