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. SAN JOAQUIN LOCAL HEALTH DISTRICT �— <br /> FORiOFFICE USE; 1601 E. Hazelton Ave,-,'Stockton, Calif. <br /> Telepho'ne�: (209),.466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. .Z1.L� <br /> 77 <br /> THIS PERMIT'EXPIRES 1 <br /> YEAR FROM DATE ISSUED Date Issueci�/a/p- ._5szm_8p7 <br /> f (Complete In.Triplicate) <br /> _ <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/rd Re la/i0 s o e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. / `" �� <br /> CENSUS TRACT <br /> Owner r s Name Phone <br /> Address _ <br /> City <br /> Cantrac or.'s Name License # j Phone ,L <br /> r TYPE , rF,WORk. Check �, �•� -�--� _. �� - -� ,..a- V <br /> f� ( ) NEW WELL . DEEPEN ./? RECONDITION' '/ DESTRUCTION <br /> ,`P• j PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 <br /> f f <br /> DISTANCE TO 'NEAREST: SEPTIC TANK , SEWER LINES i.r- PIT PRIVY_ _ <br /> i F '"TSEWAGE bISSAL FII:D` s ��- CE5SPOOL/SEEPAGE 'LUTHER <br /> i PROPERTY LIN�RRIVA DOMESTIC WELL -L�'c�P;UBLIC"' OMESTIC;WELL <br /> INTENDED USE lr TYPE OF WELL T <br /> CONSTRUCTION; 'SPECIFICATTONS� <br /> Industrial Cable .Tool Dia. of Well Excavation a <br /> Domestic'/privatey -Drilled A 4 �' <br /> ., �,. Dia. of Well Casing a . <br /> Domestic/public � Driven '' Gauge of Casing <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic" Pr-otection�. Rotary {`Type of Grout' <br /> Disposal,' Other Other Information <br /> Geoptiysieal - <br /> 1 <br /> tface Seal Installed B <br /> PUMP INSTALLATION; Contractor ' <br /> - ' 'Type of .S_ <br /> H.P. <br /> PUMP REPLACEMENT. <br /> ' ` Staff Work�Done <br /> PUMP 'REPAIR-.•A , <br /> y . <br /> � .� ._/_��^--s,ta•�e-,Work.Don ��-- _�:,,..__�: •�._, �_ , <br /> ESTRUCTION OF WELL: Well Diameter 3 <br /> ✓, Describe,�laieri&1 and Procedure -_ Approximate Depth <br /> I hereby gree to comply with all laws and regulations of the San Joaquin Local Health Distr <br /> and the Statero-f-Galifornia ert-ainin to-or-'re- ulat.i_. -'wL-1-l:construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will1 furnish-�the.,.San'Joaquin_Local Health-District e <br /> WELL DRILLERS"REPORT of the well and notify thein`liefore putting.t�he..we11 in.use.. The above ' <br /> information is true to the-best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION k <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ,. : i <br /> TITLE <br /> t ..(DRAW PLOT PLAN ON RIERSE SIDE) "— <br /> "' FOR DEPARTMENT USE ONLY <br /> `PHASE I <br /> a <br /> A�PLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> P II ROUT INSPECTION <br /> PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _-2 <br /> ti K, <br /> E H 1426 Rev. 1-74 �j <br /> 9_74 Im <br />