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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //' 3 '77 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 9 CENSUS TRACT <br /> Owner's Name �,,.,G.s `37 Phone �JI/ <br /> Address 26f 2/ 6L..,.,, sr-* - -` City <br /> Contractor's Name License #,;2, Y6a Phone iJ_,Y7zS <br /> TYPE OF WORK (Check) : NEW WELL W DEEPEN / / RECONDITION /—/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / I PUMP REPAIR 7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAI;FIELD __ CESSPOOL/SEEPAGE PIT OTHER <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 PI r� <br /> X Domestic/private _- Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing PS/ Pyc- <br /> Irrigation , V Gravel Pack Depth of Grout Seal e S"O' <br /> Cathodic Protection _ Rotary Type of Grout 7� -- <br /> Disposal Other Other Information tV1 <br /> Geophysical Surface Seal Installed By:7 /c /a►,. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. T <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work -Done <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 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT-PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� __ DATE �/' - R `7' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE IJOR PIJA$g. INAL INSPECTION <br /> INSPECTION BY _ ,-17—DATE INSPECTION BY DATE -1 <br /> or�77 _ 2M <br /> ��f <br /> E H 1426 Rev. - 1-74 _ <br />