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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFICE USE: 1601 E. Hazelton Ave. , - Stockton, Calif. <br /> 1. Telephone: (209) 466--6781_ S <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7tJ t <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued _,x_76 { <br /> (Complete In Triplicate) <br /> Application is hereby made to`lthe 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 andl.the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ; CENSUS TRACT <br /> Owner's Name G? d` �e'S�c a:�. a. . ..,....._.,. .,�. Phone '- J-q 9 �70/7 <br /> Address fMod 'C A 7 City OZL4 <br /> Contractor's Name License # y Phone <br /> TYPE OF WORK (Check) : NEW WELL -l7 DEEPEN '/_7 RECONDITION /? DESTRUCTION f'7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR/� PUMP REPLACEMENT <br /> Other <br /> DISTANCE,TO, NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY;LINE--r PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE= TYPE OF WELL ,; ;CONSTRUCTION SPECIFICATIONS (� <br /> Industrial ''{-' Cable- Tool } Ijia.' of Well Excavation <br /> Domestic/private Drilled , 4f a= .Dia. of Well Casing - <br /> Domestic/public �` .: Driven Giuge. of Casing <br /> — Irrigation -� �Grave3,_Pck-= -==Depth ofGroutSeal <br /> Cathodic ;Protec,t_ion - �� Rotarynr --Type;of Grout <br /> Disposal``, .., �1 .r y Other.. Other Information <br /> s <br /> Geophysical F Surface Seal Installed 'By: AIi: (iN <br /> PUMP INSTALLATION: Contractor _ ? : <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / -State Work Done T ` 4 <br /> PUMP REPAIR: .1-7 State WorkcDone, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR -DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: Lk <br /> PRASE 111-10-OUT INSP=ION PHASE JI;E/FINAjL, INSPECTION <br /> INSPECTION BY '­'DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - r. 4/75 2M J <br />