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G 13 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOS1 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t <br /> Telephone: (209) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermitNo. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �11 76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 3 and/or install the work herein described. <br /> This application is made in compliance with San Joaquin <br /> 1, fCounty Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local' Heaith District. <br /> JOS ADDRESS/LOCATION Z2A 7 6- CENSUS TRACT <br /> Owner's Name Phone <br />' AddressCity " <br /> Contractor's Name X77... , / Licensea2_&&2ftone <br /> TYPE OF WORK (Check)v NEW WEU_, /Z-f!'DEEPENE -,7,, RECONDITION' DESTRUCTION f 7 <br /> N/7PUMP INSTALLATION PUMP REPAIR 'PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES, PIT PRIVY <br /> SEWAGE T3ISPOaAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC. WELL`' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \� <br /> IndustrialCable Tool Dia. of Well Excavation v <br /> Domestic/private Drilled Dia. of Well Casing - <br /> f Domestic/public - Driven Gauge of: Casing <br /> Irrigation- --i -Gr-aveI Pack z *� Dep-th�of-Gr(rut--Sesl--� ,-- <br /> Cathodic Protection Rotary r Type of, Grout �� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> ,PUMP INSTALLATION: Contractor <br /> Type` of Pump <br /> PUMP REPLACEMENT: . / / (State Work Done <br /> PUMPIREPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure .• �. <br /> I hereby agree to comply with alb. laws and regulations of the San Joaquin Local health District <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 knowledge and belief. I :WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINALINSBE.CTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE Z /7_//T{ <br /> ADDITIONAL COMMENT'S: <br /> PHASE II GROUT INSPECTION PISA INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 �' - 1./79M <br />