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_ 1191SAN JOAQUIN LOCAL HEALTH DISTRICT <br />OE OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y _Z 7Cy p <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g ,a w - <br />26 <br />(Complete In Triplicate) <br />)plication is hereby made to the San Joaquin Local Health District for a permit to construct <br />'end/or install the work herein described. This application is made in compliance with San Joaquil <br />County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />�POB ADDRESS/LOCATION C _ /� <br />dner's Name <br />CENSUS TRACT <br />Phone <br />` V <br />Address 33SU City-�� <br />`3ntractor's Name License U%n 1-3i3 Phone-?(.� 3 <br />fPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION f-1 DESTRUCTION /-7 <br />` PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT /% <br />Other <br />WISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />PROPPRTV T. TMR — PRTUATR TYTMRSTTC TJPT T. PTMTTC nOMFRTTr. WRT.T. <br />INTENDED USE <br />Industrial <br />Domestic/prig <br />Irrigation <br />_ Cathodic Prol <br />_ Disposal) ', <br />Geophysid! <br />UMP INSTALLATION: <br />UMP REPLACEMENT: <br />PUMP .REPAIR: <br />ESTRUCTION OF WELL: <br />r <br />Drilled <br />Driven <br />Gravel Pack <br />Con Rotary <br />Other <br />e' <br />Contractor !� <br />Type of�_Pump <br />State Work Done <br />sr—State Work Done <br />Well Diameter <br />Describe Mater <br />hereby agree to comply with all laws and regul, <br />`and the State of California pertaining to or reg <br />after completion of my work on a new well, I wil <br />'ELL DRILLERS REPORT of the well and notify them <br />.nformation is ue to the best of my knowledge <br />_PRIOR TO GROUT ANp A FINAL�Yjf]SPECTIOI�. <br />-IGNED '� <br />=i <br />^HASE I <br />XPLICATION ACCEPTED BY i✓ <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION <br />INSPECTION BY DATE <br />C <br />Dia. of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />Surface Seal Installed By: <br />H.P. -4 0 <br />t <br />Approximate Depth <br />ons or me aan Joaquin Locai neaiui uiaLL.� L <br />ting well'construction. Within FIFTEEN DAYS <br />urnish the San Joaquin Local Health District E <br />fore putting the well in use. The above <br />belief. I WILL CALL FOR A GROUT INSPECTION <br />TITLE <br />DATE /�l <br />PHASE III/FINAL INSP <br />INSPECTION BY e'.,6 DATE <br />3/76 2M <br />