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?Ze— 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. ,z���9sp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <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� b ,� [� /Lc� -_ _ _ " CENSUS TRACT <br /> Owner's Name Phone 9� _-071-" <br /> r <br /> Address aZ� City <br /> e _ <br /> Contractor's Name '•�' License # 2 I� Phone <br /> • i <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN'/ / RECONDITION"/_/ -DESTRUCTION /� M <br /> PUMP INSTALLATION/ / PUMP REPAIR X/ PUMP REPLACEMENT I�T <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 <br /> Industrial Cable" Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pdck Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; / / State Work Done <br /> T � <br /> PUMP .REPAIR: / State Work Dane ���� �S' <br /> DESTRUCTION OF WELL: Well Diameterf 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 FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W PLAN ON MSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ .. ,.,. ,1� ^ DATE /47 <br /> ADDITIONAL COM49NTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> t._. _. 3/76 2 ,. <br /> E D 1426 Rev. 1-74 <br />