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�. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. a- <br /> Tlehon� <br /> e~ p e. •(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76--70 <br /> r it <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED Date Issued j-la-76r <br /> (Complete In Triplicate) ! <br /> Application is hereby de to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work'-E,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 /> J. <br /> JOB ADDRESS/LOCATION 1 <br /> CENSUS TRACT A` <br /> Owner's Name f` p Phone <br /> Address City �'.. <br /> Contfactor s Name License U Phone <br /> TYPE OF WORK (Check) : NEW WELL /- DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 <br /> I PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT 17 <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 <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ii Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q�4 <br /> Domestic/public i Driven Gauge of Casing 4 <br /> Irrigation ,h. Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Rotary Type of Grout V\ <br /> Disposal Other Other Information' <br /> Geophysical Surface Seal Installed By: . . . <br /> PUMP INSTALLATION: ontractor <br /> Type_ of Pump H.P. <br /> PUMP REPLACEMENT: 1,77- State Work Done <br />� PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Aescribe 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 iaell ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District al <br />; WELL DRILLERS REPORT o0ithe 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 A4P A 'i�INAL INSPECTION, k !I <br /> SIGNED AlhVIA4. TITLE <br /> l (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY I <br /> P PHASE I <br /> APPLICATION ACCEPTED' BY, DATE <br /> ADDITIONAL COMMENTS:�I <br /> PHASE II 99OUT INSPECTION PHASE 111AL INSPECTION <br /> , INSPECTION BY 'r DATE INSPECTION BY DATE <br /> elf <br /> i <br /> i <br /> E H 1426 Rev. 1-74I ;- 4/75 2M <br />