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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR(OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S= 3IO t <br /> 75-36�-J� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaqui:nj <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. k <br /> i <br /> JOB ADDRESS/LOCATION Lelan W CENSUS TRACT <br /> Owner's Name J. L. Cole Phone 463 7974 <br /> i <br /> Address _ 416 S. Cardinal City Stockton <br /> Contractor'-S..Name.Y .License-#-200794....-Phone-466- 0696 <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN -/-7 RECONDITION �� f-7ALDESTRUCTION / <br /> PUMP INSTALLATION / f PUMP REPAIR / /- PUMP REPLACEMENT <br /> Other / .J <br /> ,DISTANCE TO NEAREST: SEPTIC TANK 70 ft. SEWER LINES SO St. PIT PRIVY :C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 pinch <br /> Domestic/private Drilled Dia. of Well Casing 6 inch <br /> Domestic/public Driven Gauge of Casing .109 <br /> Irrigation Gravel Pack Depth of Grout Seal None.,,..,. . . <br /> Cathodic Protection '��* _,_ Rotary Type of Grout' <br /> Disposal , Other Other Information <br /> Geophysical. Surface Seal Installed By _, <br /> PIMP INSTALLATION: Contractor W., G. Noack ince <br /> Type _of Pump,_ Fairbanks horse 'et um. H.P. <br /> PUMP REPLACEMENT: / / State Work Done Ril 1 j2urnp and jn&jall in recased well <br /> PS P :REPAIR: L-7—State-Work,,-Done <br /> ES;TRUCTION OF WELL: Well Diameter . Approximate Depth 'lei <br /> - --Describe-Material-and ^Procedure <br /> A4� <br /> I hereby agree to comply with all-Jaws 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 FORA GROUT INSPECTION <br /> PRIOR TQIGROUTING AND A FINAL INSPECTION. <br /> SIGNED _ u F 4ry:r TITLE <br /> -�-�- <br /> " DRAW .PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE'ONLY- ' ' '_a <br /> PHASE I <br /> APPLICATION ACCEPTED BY �- DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_,,UIPFXNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> . .,\E H 1426 Rev. 1--74 1-74 2M <br />