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ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> IM Telephone: (209) 466-6781 <br /> it APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77--L4> W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 -7--77 <br /> (Complete In Triplicate) <br /> Application isohereby made to the San Joaquin Local Health District for a permit to construct <br /> r 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/LIC.1"JATION v <br /> CENSUS TRACT <br /> Owner's NamePhone _4au 97 �, <br /> IM 1 <br /> Address `` r City <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%% RECONDITION DESTRUCTION <br /> /? RUCTION <br /> PUMP INSTALLATION /—/ PUMP REPAIR '/—/ PUMP REPLACEMENT /_7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SII SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC <br /> INTENDED USE TYPE OF WELL T C WELL <br /> 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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ii Other Other Information I <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: I / / State Work Done <br /> r , <br /> DESTRUCTION OF WELL 11 Diame.t ` / C' !rr O P /��l�je D <br /> Describe Material an Procedure <br /> - <br /> I hereby agree to comply, ith all laws and O'egulatiofis of the Sajfi Joaquin Local Health t <br /> and the State oflCalifornia pertaining to or regulating well construction. Within FIFTEEN DA&S F <br /> after completionifof 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 FIN L INSPECTION <br /> SIGNED - �I ,� �.. TITLE <br /> ij (DRAW PLOT PLAN ON REVERSE SIDE) <br /> r FOR DEPARTMENT USE ONLY { <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE ]7 <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHA§&±5kTejNAL INSPECTION , <br /> INSPECTION BY iM DATE INSPECTION BY DATE <br /> E H 1426 Re' l <br /> v 1-74 X77 -. ` 2m � <br />