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to �� SAN JOAQ61N LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone : (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. <br /> -7 <br /> THIS',PERMIT EXPIRES 1.YEAR FROM.DATE ISSUED Date IssuedjAN 1 6 1978 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District-for a permit to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin , <br /> County Ordinance No. 1862-andl,the..Rules and Regulations of the San Joaquin Local "Health District. 'y <br /> 7 <br /> JOB ADDRESS/LOCATIONcENSUs TRACT <br /> Owner's Name _ �� Phone <br /> Address `v Cityil�' ..a. <br /> 74 <br /> Contractor's Name` License # j` Pkione `� .�� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 1 <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY. LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE•OF=WELL . CONSTRUCTION SPECIFICATIONS Q-ti <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private fDrilled Dia. of Well Casing <br /> Domestic/public 1 . Driven:. Gauge 'of• Casing <br /> X Irrigation . 'r11-.. .1 Gravel Pack Depth of Grout Sea! <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal 1 OtherOther Information -_ <br /> Geophysical .1 . Surface Seal Installed By: <br /> PUMP INSTALLATION: ' Contractor ,e. <br /> Type of Pump H•P. ' /-r-- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done &s,.4z <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 'Describe Material, and Procedure ' <br /> . a <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <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 the well in use... The above <br /> information is true to the best of my owledge and-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED , '�- ITLE g�_ . <br /> ((DRAV PLOTIPLAR ON REV SE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I 'Zi <br /> APPLICATION ACCEPTED BYZ DATE R <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEIII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �• •� <br />{ <br /> n;77 , 2M 5 <br /> A E H 1426 Rev. . 1-74 " <br />