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T <br /> �. . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'f'Or- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR 'WE LL CONSTRUCTION OR PUMP PERMIT Permit No. 7-/Vff <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED Date Issued //-/5/- 77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District f.or a permit to construct <br /> and/or install the work herein described., This application is made in compl.iance .with San Joaquin <br /> County Ordinance No. 1862 and the Rules and-Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION sy A, CENSUS TRACT <br /> Owner's Name ov Phone 7 7-- <br /> Address 4rN-V Cit <br /> Contractor's NameLicense #2yrPhone <br /> a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP.REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES .!/dl,.�y� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /Gll ' CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL ' <br /> INTENDED USE ;•y TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ar Cable Tool Dia. of Well Excavation -Z- <br /> --�- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 1 rrigation ` , 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection l Rotary Type of Grout ^4 <rL <br /> Disposal 1 Other Other Information' <br /> Geophysical " Surface Seal Installed By: koss. T <br /> PUMP INSTALLATION:— Contractor <br /> Type of. Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work ]lone <br /> DESTRUCTION OF WELL: Well Diameter xt Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all 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 puttirig. 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 /> PRIOR TO GROUTIN AND A FINAL INSPECTION. <br /> SIGNED ' 41& TITLE <br />` (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I _ <br /> E, APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P44V,4I ROUT INSPECTIO P II/FINAL INSPECTION` <br /> INSPECTION BY -DATE WZ2e 7 INSPECTION BY DATE <br /> �i <br /> n�77 2M <br /> E H,1426 Rev. 1-74 _ I <br />