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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ 77 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> - <br /> (Complete <br /> Triplicate) for <br /> Application is hereby made to the San Joaqu n Local Health District foraer ' <br /> p m�.t 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/LOCATION14 <br /> . �LG� ` CENSUS TRACT <br /> I <br /> Owner's Name � I <br /> Phone -?f.,?--,��,_� <br /> Address '7 6 j <br /> City --• -- <br /> �`-� <br /> Contractor's Name P License IY(Q1- 373 Phone369'-r <br /> TYPE OF WORK (Check) : NEW WEL� / / DEEPEN ' ! <br /> _/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR f-V'f PU�'T REPLACEMENT /_ <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY -LINE - PRIVATE DOMESTIC WELL ' �UBLIC DOMESTIC WELL <br /> 'INTENDED USE TYPE OF WELL <br /> F CONSTRUCTION SPECIFICATIONS <br /> ilndustrial A E . - Cable Tool Dia. of Well Ekcavation V' <br /> $Domestic/private�i�� ... j.A Drilled Dia, of Well C sing <br /> mestic%publ- c=-.----�--- -4 <br /> Driven Gauge of Casin <br /> Irrigation <br /> 7I,- Gravel Pack Depth of GroutiSeal <br /> `Cathodic'Prote-ction `',-a Rotary Type of Grout Q <br /> :Disposal T OtherOther Information _ _.-- <br /> (Geophysical�'�° � <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor fi <br /> — � f <br /> Type of]Pump H.P. <br /> _._ _ A.- .. - - 1a <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter � <br />"`—� -- ! Approximate Depth <br /> i Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San'J,oaquin Local Health District <br /> and the State of California pertaining to or regulating well 'cons1t`ruction. 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 notifythem before ore putting the well in use. The above <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR;TO GROUTINGAAND A FIAL INSPE ION. <br /> SIGNED TITLE <br /> f DRAW PE' T PLAN ON RE E—kSE S�E <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> •`� •` _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 2M s <br />