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f <br /> R SAN JOAQUIN LOCAL HEALTH. DISSTyRIOT - <br /> Ave. , tockton, Calif. <br />_-FOE OFFICE USE: 1601 E, Hazelton , <br /> Telephone: (2.09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> 76 _io IgAt/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' Date Issued j� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fox a permit to construct <br /> d. This application is made in compliance with San'Joaqu3,x <br /> and/or install the work hereon describe <br /> the Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and <br /> � � lG CENSUS TRACT <br /> JOB ADDRESS/ <br /> I <br /> S^ Phone i <br /> Owner's Name f <br /> t City <br /> Address <br /> Contractor's Name <br /> License hone <br /> TYPE OF WORK (Check) : NEW WELL / -7 <br /> DEEPEN/ / RECONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION-r/ PUMP-fft AIR /-/� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES{ PIT PRIVY <br /> SEWAGE.DISPOSAL FiRIVATE <br /> ELD /LS �EEPAGE PIT,IO® OTHER Y y <br /> PROPERTY LIN DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL W CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool -Dia. of Well Excavation <br /> Drilled Dia. of Well Casing p <br /> Y Domestic/Private Driven Gauge of Casing <br /> Domestic/public Q <br /> E Irrigation �.� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection + Rotary Type of Grout 4„ <br /> Disposal d Other _ Other Information <br /> Geophysical Surface-Sea1 Installed By: <br /> r PUMP INSTALLATION: ContractorH,p, <br /> Type: of Pump <br /> E <br /> PUMP REPLACEMENT: / / ( State Work`Done <br /> PUMP REPAIR: /-7 State.Work Done <br /> DESL: <br /> DESTRUCTION OF WELD Well.Diameter <br /> 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 DAY <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 /> 1 PRIOR TO GROUTING AND A FINAL INSPECT IO TITLE <br /> SIGNED <br /> W- �P. T PLAN O RE FRSE SIDE) <br /> FOR DEPART T USE ONLY <br /> PHASE I k DATE.` <br /> —4-Z6— <br /> APPLICATION ACCEPTED BY l <br /> ADDITIONAL COMMENTS: PHASE I I/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE T <br /> INSPECTION BY I DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />