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'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F06 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, ,J'� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein 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 /> JOB ADDRESS/LOCATION - <br /> +� CENSUS TRACT <br /> Owner's Name jo Phone ZV-3.D <br /> Address7-7 City ` � , <br /> / 4 <br /> ,Contractor's Name er"' License � <br /> .. _ t. ,26_.-57,6/ Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION /ZPUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ fp?'4SEWER LINESPIT. PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ' ' OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC—WELL PUBLIC?DOMESTIC WELL, <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTIOW SPECIFICATIONS <br /> Industrial . of Dia. °of- We11-Excavation, <br /> Domestic/privateDrilled Dia. of Well Casing rA J ! <br /> Domestic/public Driven Gauge of Casing <br /> ry.,.��on <br />—�— -- Gravel Pack Depth of Grout Seal <br /> - Cathodid Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ~� Surface Seal installed B <br /> 77 A­eiC. <br /> PUMP INSTALLATION: :'Contractor <br /> Type of. Pump u r H.P. 3 <br /> PUMP REPLACEMENT:; -�,,..,.; { <br /> / / State Work Done <br /> PUMP .REPAIR: / / State` Wofrk Done <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#-:moi <br /> and the State of California pertaining to or regulating we11 "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 /> TELL DRILLERS REPORT of the well and notify them before putting the.-well in use.. The above Y <br /> information is true to the best of my knowledge and- belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTING AND A,FINA.L INSPECTION. <br /> SIGNED <br /> TITLE iA <br /> (DRAW T PLAN ON REVERSE SIDE) I.' <br /> FAR DEPARTMENT USE ONLY <br />?RASE 1 •�-� <br /> IPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - / <br /> PHASE,. II G PE ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY ,,I' l DATE ! a'77 <br /> 40�� <br />_�E H 1426 Rev. 1-74 1177 214 <br />