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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: '41601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6.781. <br /> APPLTCA'iIQN FOR WELL CONSTRUCTION OR PUMP PE:J4I1 Permit No. ZZ-"StJ <br /> g THIS PEPUMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IE•sued ,�--e 77 <br /> (CLtmplete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for P permit to construct <br /> ,and/ install the work herein described. This application is made in compliance with Sat Joaquin <br /> County Ordinance No. 1862 and the Rules and Regui-ations of the San Joaquin Lc+cal Health District. i <br /> JOB ADDRESS/LOCATION �.�5 �� /-JC-�/� C- - CENSUS TRACT <br /> Owner's ;lame I 1. �� f _ — Phone <br /> Address -i ,_/]//_C7<< ✓'�•�l C�/� --- City ' <br /> Contractor's NameY�GL-�iC/Z _ License Phone - IZc� ;••; <br /> TXPEiO 4ORK (Check): NEW WELL /DEEPEN / T RECONDITION /-7 DESTRUCTION /7 ° <br /> PUMP INSTALLATION / / PUMP REPAIR I ; PUMP REPLACEMENT I�T <br /> �. <br /> 4r Other 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD GESSPGOL/SEEPAGE PIT OTHER N i ' <br /> `.� PROPERTY .LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel]. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic)public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection RotType of Grout <br /> Other Information e <br /> Disposal1 <br /> Ceophy'sical Surface Seal Installed B .,°� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. — 3 <br /> -PUMP REPLACEMENT: - / / State Work Done <br /> PUMP .REPAIR: / J State Work Done <br /> r Well Diameter Approximate Depth <br /> . DESTRUCTION OF WELL: . ,.- <br /> b Describe Material and Procedure k ' <br /> .I hereby agree to comply with alllaw3 and regulations of the San Joaquin Local Health District 4 ' <br /> and the State of Cal_:.fornia pertaining to or regulating well',=struction. 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 -tiatify them before putting the.well in use. The above <br /> �? information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL IN PECTION. a. <br /> SIGNED r �� ----*a^•�: ,.; . <br /> —c '� DRAW PLOT PLAN ON REVERSE SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I � ^� <br /> DATE .S- L % <br /> APP LOCATION ACCEPTED BY <br /> w ADDITIONAL COMMENTS: - <br /> PHASE II GRO17T INSPECT N PHASE III/FINAL INSPECTION r <br /> * INSPECTION BY DATE INSPECTION BY / DATE ( ';,.����1 ` <br /> w' 3/76 2M <br /> E H 1426 Rev. 1-74 <br />