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1 SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 4,/ . <br /> 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Data Issued <br /> (Complete In Triplicate) i! <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 Sari Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1 <br /> JOB ADDRESS/LOCATION / 73 Al •. ��� CENSUS TRACT <br /> Owner's _Name Phone <br /> CityZ-0 <br /> Address <br /> Contractor's Name [ !� License #�? 0/6 Phone,'!!! 7���9 <br /> # 3 <br /> TYPE OF WORK (Check) : NEW WELL ,DEEPENS/�/ ,RECONDITION /_/ DESTRUCTION /� + <br /> __PUMP"INSTALLATION �" ' PUMP'�R-PAIR '/ / PUMP'REPLACEMENT--f ter"- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK g'®-f SEWER"LINES- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ;TYPE OF WELLY„ I CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable_To"ol Dia. of Well Excavation /0 <br /> _ <br /> Domestic/private j Drilled Dia. of„Well Casing 6" <br /> Domestic/public Driven `"--__'`Gauge of Casing `Z <br /> Irrigation Gravel Pack Depth .of Grout Seal <br /> Cathodic Protection T Rotary Type of�Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal -Installed By: J. <br /> ZGS]�f <br /> PUMP INSTALLATION: Contractor <br /> Type of_Pump _ A.-vH.P. <br /> PUMP REPLACEMENT: / / '. 'State Work Done <br /> T � <br /> PUMP .REPAIR: / / State Work Done - <br /> .. <br /> E DESTRUCTION OF WELL: Well Diameter Approximate Depths <br /> Describe Material and Procedure <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 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 A FINAL INSPECTION. <br /> r SIGNED ' G TITLE�� �� <br /> W APt', AN 'CfN REVERSE- SIDE) <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I DATE P-,]'� <br /> 4 APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHAS II/ INSPECTION <br /> INSPECTION BY DATE `INSPECTION B - DATE <br /> Y.4 <br /> 3/76 2M <br /> .E H 1426 Rev. -JzA <br />