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SAN JOAQUIN LOCAL,;,.ALTH DISTRICT <br /> 5_R:(OFFICE USE: 1601 E. Hazelton:-Ave:,`:Stdckton, Calif. <br /> Telephoner (209) 466=0781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ;:6af <br /> THIS PERMIT EXPIRES l' `YEAR. FROM DATE ISSUED Date Issued LZff-77 , <br /> a (Complete-Ira, Triplicate) i <br /> Application is hereby made to�the San Joaquin :Local>�Health District for a permit to coristruct <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 and .Regulations of the San Joaquin Local Health District. { <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 5 �' L e_S7I`.- Phone <br /> Addresd z- P':�j3 0 �c -F b�, �. _ _- . City 00 <br /> Contractor's Name A)w-� i /Jf� 7''� �.�_ License # Phone,5-ff -T6 <br /> F � <br /> TYPE OF WORK .(Check): NEW WELL /_7 DEEPEN f_1 RECONDITION /_7 DESTRUCTION f 7' <br /> PUMP INSTALLATION /� PUMP REPAIR" /—/­PUMP PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 'U <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS {U <br /> Industrial Cable Tool Dia. of Well Excavation (� <br /> Domestic/private Drilled ...-Dia. of Well Casing d: <br /> Domestic .Driven. v A­Gauge$of-Casing Y <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surf ace_Seal_Installed By:__ <br /> PUMP INSTALLATION: Contractor s z) ..-� �1`ll•'4 qct <br /> T `Type of Pump A.P. • y /�� � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-,:REPAIR: /7 State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material.and Procedure <br /> I hereby agree to comply withs 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 deli and notify them before putting- thewell in use.. The above <br /> information is true to the be•st-of my knowledge and"belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG OUTING AND A FINAL' INSPECTION.. <br /> SIGNED _ ��-t�. TITLES L - <br /> ,+ (DRAW PLOT PLAN ON REVERSE SIDE�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I DATE -1g <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTION PHA ;4I4gNINSPECTI9� <br /> INSPECTION BY DATE- INSPECTION BY DATE <br /> ..,y....t... ... r...,. .1� ...t ... .p, ..., .....:ems.......- ..-_-_..a. <br /> i , <br /> E H 1426 - Rev. .1-74 1-74 2M <br />