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Co SAN ,JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> ' ` Telephone: Permit No. <br /> (209) 466-6781 ?7_L3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1' YEAR FROM DATE ISSUED Date Issued Z] <br /> .� �,✓ <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 ands the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION ti %� Y CENSUS TRACT <br /> Owner's Name 0,✓ 1 h Phone <br /> 1 J � <br /> Address ':3`L t7( 6 City,'" <br /> /I � ; License �� Phone <br /> Contractor's Name'_S�J ®AI F-� ' � - - _V4; ` <br /> TYPE OF WORK (Check) :` NEW WELL / / DEEPEN /N/ RECONDITION /_/ DESTRUCTION /_7— - <br /> - _ <br /> PUMP INSTALLATION / I PUMP REPAIR PUMP REPLACEMENT <br /> Other `/ / <br /> i <br /> DISTANCE. TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY L-INE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ?, <br /> 'Industrial Cable Tool Dia. of Well Excavation � I <br /> Domestic/private Drilled Dia.'-of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth o£' Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout <br /> Ik Disposal 1 Other Other Inforx€iation <br /> Geophysical. Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor <br /> Type {of .Pump H.P. / ,r <br /> PUMP REPLACEMENT: / / (State Work Done <br /> PUMP REPAIR: 1State Work Done' Q <br /> F Depth <br /> DES-TRUCTION OF WELL: Well Diameter Approximate De p <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 kn6wle e a5d elief. I WILL -CALL FOR A GROUT INSPECTION <br /> t PRIOR TO GROUTING AND A FINAL INSPEC <br /> SIGNED. -f (TLE <br /> 91 (D W LOT PLAN ON REVVRSE SIDE) <br /> ' OR DEPARTMENT USE ONLY ? <br /> PHASE I DATE ,9- 72 <br /> k APPLICATION ACCEPTED BY -- -- <br /> ADDITIONAL COMMENTS: r <br /> PHAS II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> DATE LA <br /> INSPECTION BY DATE _ INSPECTION BY <br /> 6/77 2M <br /> ri rY 1. 1G n =_ 7 __71. __ - _... <br />