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FOHSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R FOFFICE USE; �"`'` 1'601 E. Hazelton Ave. , Stockton Calif. <br /> 3 Tele bone : (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �• <br /> S4 cc � THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -t <br /> i (Complete In Triplicate) <br /> APplication is hereby made to the San Joaquin' Local Health District for a permit to construct <br /> and/or 'inystall the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 'I862 acid the Rules and Regulations of the Saiz Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name y Phone 21 F <br /> Address <br /> t City <br /> Contractor's Name <br /> erase /7��hongn3-9 3 <br /> TYPE OF WORK (Check) : NEW WELL N, DEEPEN / / RECONDITION /_% DESTRUCTION /- � <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / ` <br /> DISTANCE TO NEAREST: SEPTIC TANKJp6 SEWER LINES/D Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> -- _ <br /> PROPERTY 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 ��rilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation YGravel Pack Depth of Grout Seal <br /> Cathodic Protection I Y Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> E <br /> PUMP INSTALLATION: Contrractor <br /> Type of Pump <br /> ff H.P, <br /> it PUMP REPLACEMENT: / / State Work Done r <br /> PUMP .REPAIR: <br /> / / 5tate ork Done A964t <br /> 110?� P a r�- cJ� .reit <br /> DESTRUCTION OF WELL: s W 1wDiameterb / Approximate Depth <br /> scribe ,f <br /> 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 thewell 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 GROUTI G ANDA WINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> ( RAW PLOTPLANON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY 13 <br /> yr DATE (S'7 <br /> ADDITIONAL COMMENTS.: <br /> PHAS ISI GROU INSPECTION PHASE III/FI AL INSPECTIO <br /> INSPECTION BY ATE I-7--77 INSPECTION BY DATE Q <br /> E H 1426 Rev— 1-74 1--74 <br />