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SAN JOAQUIN LOCAL HEALTH- DISTRICT } <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' j <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- S7P'P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-_,71_7;7 <br /> E <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 <br /> / � � ��N4 GJ �� '� cENsus TRACT <br /> Owner's Name <br /> Phone 133,1,23/Z <br /> Address City <br /> Contractor's Name <br /> 'License Phone <br /> _ r y <br /> TYPE OF WORK (Check):NEW WELL /% DEEPEN -/ RECCONDITION„/�[-_DESTRUCTION /__7PUMP INSTALLATION / / PUMP REPAIR:/ / PUMP REPLACEMENT <br /> Other / / �� .. T <br /> :,. <br /> DISTANCE TO NEAREST: SEPTIC- TANK" SEWER • s PIT PRIVY <br /> SEWAGE DISPOSA-b-FIELD CESSPOOL/SEEPAGE PIT OTHER 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL, � ? <br /> INTENDED USE -TYPE OF WELL 1 ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabin-T-ool . Dia., of€ Well Excavation �1 <br /> Domes tic/private Drilled Dia. -of(j Well�Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> °Cathodic. Pro.tetti6n i Rotar.Y .. Type oft Grout 9 <br /> Disposal � �-Other Other Information <br /> Geo "si'c-al- ti, tea L- <br /> P hy Surf ace4Sealr.Installed B 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P: v <br /> i <br /> PUMP REPLACEMENT: .�f <br /> /J� State Work Done V <br /> PUMP REPAIR: / / State Work Done -� - <br /> S <br /> DESTRUCTION OF WELL: Well Diameter j 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 FORA GROUT INSPECTION <br /> PRIOR TO GROU NG AND A F AL INSPECTION, <br /> SIGNED TITLE x.aE <br /> {DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY 1 l �� DATE <br /> ADDITIONAL COMMENTS: V <br /> PHASE II GROUT INSPECTION V PHASE IIfT/FINAL INSPECTION ' <br /> INSPECTION BY J DATE INSPF,CTION B DATE ��i' <br /> E H 1426 REE- 1-74 f, 1177 _ 27 <br />