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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0-itOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-4.?.f/-1 <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - -76 <br /> it , (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 /> //7,?,? w <br /> JOB ADDRESS/LOCATION T , - mo n, CENSUS TRACT <br /> ry , <br /> Owner's Name ,omylt« � <br /> Phone f .1/2 R <br /> Address. ._../j <br /> City _ <br /> Contractor's Nameu4fw,�ekw <br /> ' <br /> License # 01/3 Phone <br /> TYPE OF WORK (Check): NEW WELL -/F' DEEPEN '/-7 RECONDITION /7 DESTRUCTION %'? <br /> PUMP INSTALLATION..../77_:.PUMp REPAIR. /_7.5 PU1'P_REPLACEMENT f f <br /> Other /_7 <br /> -- <br /> DISTANCE TO NEAREST: SEPTIC TANK /17/ SEWER LINES �_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE„PIT OTHER <br /> PROPERTY LINE - PRIVATE <br /> STIP WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL — CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable- Tool Dia. -of-Well Excavation 1 <br /> Domestic/private i Drilled ' Dia. of'Well Casing X& J <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal i <br /> x __Cathodic ProtectionRotary Type of Grout' <br /> Disposal _ Other Other Information <br /> " Geophysical Surface Seal Installed B • <br /> PUMP .INSTALLATION: � <br /> . Contractor , <br /> + Type of Pump <br /> H.P. <br /> PUSH' REPLACEMENT: / / State Work Done ; <br /> i . . <br /> PUMP !REPAIR: /7 State Work Done <br /> ES.TRUCTION OF WELL: Well .Diameter W <br /> Approximate Depth <br /> Describe- Mate <br /> rial 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 <br /> g g 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 FORA GROUT INSPECTION <br /> PRIOR TO OUTING.AND A INAI IN CTI <br /> "SIGNED . <br /> ` TLE <br /> (DRAW P OT P N SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> APPLICATION ACCEPTED BY r ". Z DATE :31 . <br /> ADDITIONAL COMMENTS: i <br /> POUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY; DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />