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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE, USE: G 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �i Telephone: (209) 466-6781 7 7- � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 7. 2 3?,SW <br /> 0 �.. <br /> �! THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> u (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 Regulatio s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �!7 C. _L CENSUS TRACT� �lti <br /> ��Owner's Name Phone C ay'7 <br /> Address ' Ci <br /> .F <br /> Contractor's Name 1 License # 02SO/0 hone <br /> r- <br /> TYPE OF 'WORK '(Check) :' NEW WELL /ZrID EEPEN %—/ RECONDITION /_/ DESTRUCTION /-7- <br /> 'PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other -- <br /> j� <br /> DISTANCE TO NEAREST: SEPTIC TANK! ' SEWER LINES T PIT PRIVY - <br /> ` SEWAGE DISPOSAL FIELD cJl CESSPOOL/SEEPAGE PIT - OTHER =� <br /> PROPERTY LINE --,"PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 4 INTENDED USE . !' TYPE OF WELL CONSTRUCTION SPECIFICATIONS � . <br /> Industrial �j� Cable Tool Dia, of Well Excavation <br /> Domestic/private�� Drilled'' Dia, of Well Casing <br /> Domestic/public IP -; Driven 4 Gauge of Casing <br /> Irrigation Graver Pack Depth of Grout Se <br /> Cathodic Protection j �A Rotary j Type o£ Grout - r <br /> Disposal{ s: +`S ' �," Other i Other Information <br /> Geophysical•- !� -. ` Surface Seal Installed B , <br /> 73 <br /> PUMP INSTALLATION: J a iContractor' <br /> s ilype--6f Pump4-- -j <br /> PUMP REPLACEMENT: J / State Work Done <br /> — <br /> PUMP .REPAIR:.._-_- ,/ / State.Work Done _ <br /> DESTRUCTION OF WELL: Nell Diameter Approximate Depth <br /> I�Describe Material and Procedure W <br /> I hereby agree to comply with all lavas 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 myl!'work on a new weijl, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and ify ,them before putting the. well in use. The above <br /> info r ion is true toj�the best o kn ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AND A FI N. <br /> SIGN a, <br /> TITLE ^ - <br /> ,j D L T PLAN 'ON REVERSE SIDE) - ` <br /> FOR DEPARTMENT USE ONLY <br /> j PHA <br /> APPLICATION ACCEPTED BY DATE-/3P-7 <br /> ADDITIONAL COMMENTS: I� <br /> PHASE' II GROUT INSPECTION. PHASE III/FINAL INSPECTION <br /> f INSPECTION BY C• - M DATE 1,4- Lo- 27 „INSPECTION BY j/J DATE <br /> j 3/76 2M <br /> � E H 1426 Rev. 1-7A �� ....... <br />