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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton AveA, Stockton, Calif. <br /> :�lTelephone. (2 9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -Z) o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued G-2-�-171f <br /> (Complete In Triplicate) 710? _ !Application <br /> O-- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the workl1herein 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 /> `f s 9.3 9 cu- <br /> JOB ADDRESS/LOCATION I'I rifl_7fi�� if -.,� � �(El�t sFP1i. . „ - CENSUS TRACT <br /> Owner's Name one <br /> Address Il5;govz 7 _ City w <br /> Contractor's Name License # p2 08 Phone <br /> TYPE OF WORK (Check) : NEW WELL /�DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION J_7 <br /> PUMP INSTALLATION '/ I PUMP REPAIR/ / PUMP REPLACEMENT /-J <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK =,�o SEWER LINES gf&,p"- PIT PRIVY 0?00 <br /> SEWAGE DISPOSAL FIELD i1 £ CESSPOOL/SEEPAGE PIT OTHER��ao' <br /> • PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation � ,.. Gravel Pack Depth of Grout' Seal <br /> Cathodic Protection .w` �/ Rotary Type of Grouter <br /> Disposal Other Other Information <br /> Geophysical Surface .Seal Installed-By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / State Work Done <br /> PUMPREPAIR:.. ..- . / State -Work,Done - - - - - - Zrl <br /> DESTRUCTION 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 Ca7lif6-inia-per taini­ng-to=or-regulat ng wel-1' ons_truction.- Wi.thin_EZFTEEN_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 ofll, the well and notify them before putting the..well in use. The above <br /> E information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> l PRIOR TO GIROUTING AND_411FJNAL INSPACTION, <br /> r SIGNED TITLE lb <br /> IM DRAW- T PL 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> I APPLICATION ACCEPTED BY DATE 7 7 <br /> ADDITIONAL COMMENTS: Ip <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> I INSPECTION BY I. DATE INSPECTION BY DATE <br /> 3/76 <br /> E .H 1426 Rev. 1-7' , y <br />