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F W <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQP: QFF CE USE 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <br /> � T {Complete In Triplicate) <br /> Application is hereby made to the Sat: 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' Joaqui:t <br /> County Ordinance No.. 1862' ard the Rules and Regulations of. the San Joaquin Local Health District. <br /> :. <br /> JOB ADDRESS/LOCATION-... '.el GENS <br /> [TS TRACT <br /> ' Owner's Name <br /> i // // � Phone <br /> Address S, / # , ia / <br /> City CE74 44?4i- - <br /> f Contractor's Name License �� � <br /> i F /jl,,7 L.-Phone Va 1, 76 74 <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION I I PUMP REPAIR L)e7 PUMP REPLACEMENT f <br /> I Other/? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE IDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> -. Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. o€ Wel] Casing <br /> Doestic/public I Driven Gauge of Casing <br /> x Irrigation iGravel Pack Depth of Grout 5ea1 <br /> Cathodic Protection I Rotary Type of Grout' <br /> Disposal Other Other.In'formation <br /> Geophysical Surface .Seal Installed B <br /> PUMP INSTALLATION: Contrattor p 040 <br /> Type of Pump l V H,.P. <br /> PUMP REPLACEMENT: C1 State Work Done — <br /> PUMP :REPAIR: /Y7 State Work Done ? <br /> .,7 � . <br /> - E&TRUCTION OF WELL: Well Diameter <br /> Describe. Material and Procedure Approximate Depth <br /> I hereby agree to comply withfall laws and regulations of the San Joaquin .Local Health District <br /> and the State of California pertaining-to or regulat,ingLwell-coristruction� Within F'IF'TEEN DAYS <br /> after completion of my work oii a new well, I will furnish tike 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 ande£. I WILL CALL FOR A GROUT INSPECTION , <br /> PRIOR TO GROI1 ING AND A FINAL =INSPE IQN. <br /> <SIGNED <br /> T.M.E <br /> I DW P flN R . SE SIDE <br /> •t <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 7 �7 <br /> ADDITIONAL COMMENTS- 7-7-64DATE f <br /> PHASE II.GRQUT INSPECTION I IPHASE TII TNAL INSPEC N <br /> INSPECTION BY _� DATE INSPECTIONBy DATE <br />' E H 1426 Rev. 1-74 <br /> 1-7LA ')M <br />