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VVV SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE:-. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - ` '-` Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -6_2 &/ <br /> 76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is'bereby 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. 1$62 and the Rulnd�Regulations of the San Joaquin Local Health District. _ <br /> �? J <br /> JOB ADDRESS/LOCATION G L CENSUS TRACT " <br /> Owner's Name 7' Phone w y <br /> Address e/ CL •� City S / C�¢Ge <br /> Contractor's Name LL Q[� Q <br /> �' License #2,9gq,6 I Phone 7 /_n_LL <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/ / RECONDITION /7 `DESTRUCTION /7 ` <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 ., <br /> Other,/ / <br /> DISTANCE. TO NEAREST: SEPTIC TANK 135"' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ~' CESSPOOE/SEEPAGE PIT OTHER <br /> PROPERTY LINE -,PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC WELL <br /> �... <br />(f 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 Gravel4.Pack Depth of Grout Seal ; <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal ' Other Other Information - <br /> Geophysical Surface Seal Installed By. a, <br /> ,- 20� 26 x`71 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P."; <br /> PUMP REPLACEMENT:- / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> k <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Land the State of Californiapertaining to or regulating well-construction. Within FIFTEEN DAYSter completion of my work on a new well, I will €urnish the San JoaquinLocal Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> .formation is true to the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> UOR TO GROUTING. AND A FINAL INSPECTION. , <br /> GNED '� TITLE <br /> j/ Lu KAW PL'T P 'ON REVERSE SIDE <br /> t FOR DEPARTMENT USE ONLY <br /> kSE I <br /> `�ICATION ACCEPTED BYDATE S <br /> .TIONAL COMMENTS- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPECTION PHASE IIA/FINAL INSPECTION <br /> ECTION BY R, DATE INSPECTION BY DATES <br /> 3/76 <br /> H--1426 Rev. '1-74 <br />