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I <br /> SAN JOAQUIN LOCAL 'HEALTH DISTRICT- <br /> FOR±OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif: . <br /> Telephone: " '(209) 466=6781 <br /> A APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. l <br /> $ <br /> !� THIS PERMIT EXPIRES 1,%YEAR FROM DATE"ISSUED' Date Issued A 19-7� <br /> .. (Complete In Triplicate);, t <br /> Application is hereby made to the San Joaquin LocaL Health District-1dr' 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 ADD 'SS/I:OCATION <br /> . 'CENSUS TRACT <br /> Owner's Name ('_ Phone <br /> Address) v 7JW dcL S70 City <br /> j. <br /> Contractor's Name L'✓W �� J License i6_X-3_2*hone4"_-__g a_7_T <br /> TYPE OFWORK (Check): NEW WELL /7 DEEPEN/7 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /7 PUMR REPLACEMENT <br /> Other / I 'C!�Iq;LJ 'C11.07- `A . = ' r/ 7-/DN - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC 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' r , <br /> Domestic/public Driven Gauge o f, Casing C <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> C4thodic Protection Rotary Type of Grout <br /> Disposal ' Other Other,.Information j <br /> —Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor oc;7p''K �UIF-Z-- - <br /> �� Type of Pump } ♦ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />...P .REPAIR: ..r.E-- --s tate Work"Done-A- -_,_ <br /> E54RUCTION 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. thewell in use.. The above <br /> information is true to the-best of my knowledge -and belief'. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION: <br /> SIGNED ': TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE-V <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: f <br /> I�.. PHASE� II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE -' INSPECTION BY DATE <br /> tiI <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M. <br />