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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. ZA_>>u jo <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8 a w- 6 <br /> (Complete In Triplicate) -- <br /> ppiication is hereby made tolthe San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein) described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 0C166211 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LccOCATIO,,NppCJ /dtdfi �Tirr:� I27 f7 w�g�j' L � CENSUS TRACT <br /> Phone <br /> ddress 13 3 City <br /> ontractor's Name License #f(o 2373 Phone36 3 <br /> 'YPE OF WORK (Check): NEW WELL /� DEEPEN '/_� RECONDITION /� DESTRUCTION /� <br /> PUMP INSTLATION REPAIR � PUMP REPLACEMENT /7 <br /> AL <br /> Other /_7 <br /> `L <br /> )ISTANCE TO NEAREST: iSEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ! CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY,LINE - PRIVATE DOMtSTIC WELL — PUBLIC DOMESTIC WELL W <br /> INTENDED USE j E OF WELL I CONSTRUCTION SPECIFICATIONS <br /> TY <br /> Industrial (, `f� Cable Tool Dia, of Well Excavation d <br /> Domestic/privatk Drilled Dia. of Well Casing <br /> _ <br /> Domestic/public � ' �1 Driven Gauge of Casing <br /> _ Irrigation C il( Gravel Pack Depth of Grout Seal <br /> Cathodic. P-rotec ion t ? Rotary Type of Grout . z <br /> Disposals ) ; Other Other Information <br /> Geophysidal! T a �(�1 1 Surface Seal Installed By: <br /> ? �J�e emcee i6. �� /C <br /> 1 <br /> UMP INSTALLATION: 'Contrac -hr <br /> T e of Pump ){pw® H.P. Q <br /> PUMP REPLACEMENT: El- State Work Done- <br /> . <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Pro lure <br /> qr <br /> I hereby agree to comply with all laws and regul*ions of the San Joaquin Local Health District <br /> and the State of California pertaining to or regtdl/ating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I wil4ftrnish 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 ylue to the best of my knowledge 'nd'belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT&g ANR A FINAL SPECTIO <br /> SIGNED TITLE <br /> DRAW <br /> PLOT PLAN 'ON RE RSE SIDE " ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 1 ]� <br /> APPLICATION ACCEPTED BY DATE A& <br /> ADDITIONAL COMMENTS: If If <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY e- DATE /6 _ <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 - <br />