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SAN JOAQUIN LOCAL HEALTH. DISTRICTZ�r—O <br /> FOH OSFFICE^"USE I`" 1601 E. Hazelton Ave. , Stockton, Calif.. /p "R a^1140 Y-61`. <br /> Telephone: (20;) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � y f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �'rh7-77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> ,FOA ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone — `� �-- <br /> 01 / <br /> Address City ! _ <br /> Contractor's Name License � Phone <br /> TYPE OF WORK (Check) , NEW WELL / / DEEPEN '/ / RECONDITION DESTRUCTION DESTRUCTION /� <br /> ..-PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO'.NEAREST: SEPTIC TANK e 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 zz <br /> �Irrigati.on Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary- Type of Grout r <br /> i Disposal Other Other Information �- <br /> Geophysical Surface Seal Installed By: <br /> ,�csg-�aN <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PLOP.-_REPLACEMENT: /j State Work .DoneY <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 tothebeIZECTION. <br /> my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTIN AND A I <br /> SIGNED TITLE nc <br /> W PLOT PLAN ON REVERSE SIDE) <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE TI G NS ECTION PHA /FIN INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE G <br /> - / <br /> ' 1/77 _ 214 <br />