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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. .7 7,3 1/C <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-7- 3/6 0) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 _�7 F 6 r2 S, 57F CENSUS TRACT <br /> Owner's Name � ��N�+ - �/�f-� ... _ . Phone 0.3 ?L <br /> Address 1 "_ 5E/d MER RA. City E,< 441- -0 <br /> Contractor's Name ��( Z&C , License ���o�Phone — <br /> i <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN/ J RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR / / 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 �. <br /> Industrial Cable Tool Dia. of Well Excavation Al <br /> Domestic/private Drilled Dia. of Well Casing /a " <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Zc <br /> PUMP INSTALLATION: Contractor _ /✓0 eU12224 Z&C. <br /> Type of Pump B1o✓je— H.P. <br /> y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUNP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 GROU ING ANP A ZJNAL INS ECTION. <br /> SIGNED TITLE <br /> DRAW PL T' PLAN ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE �� INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br /> � <br />