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s <br /> SAN JOAQtjWN LGCAL HEALTH DISTRICT ' <br /> FOReOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-6 3/u <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6_IeA_ <br /> (Complete In Triplicate) <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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �? , d " ' 'a3 3— �- ! h'1 o* KoS-re re. RkENSUS TRACT <br /> Owner's Name 01 N Phone 3 g z <br /> Address b O / City C y <br /> Contractor's Name )-- <br /> TYPE <br /> , d3 <br /> -�� � N � � .� iJ +�� License �?908J3 Phone � `' 1 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN J-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / 7 PUMP REPAIR /_7 PUMP REPLACEMENT ff <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PRdPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of 'Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing " `v <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout Q <br /> Disposal Other ` Other Information S.4)9 0 Lu fV <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:. <br /> ' ,L7 State Mork Done . � <br /> ES-TRUCTION 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 REPaeto <br /> of the well and notify them before putting the. well in .use.. The above <br /> information is tr the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A FINAL INSPECTION. , <br /> SIGNED TITLE Oh�rne..J <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION A PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E R 1426 Rev. 1-74 1-74 2M <br />