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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFF:CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 0 L v 4VL P SAc-TD n/f"bcvsUs Tr.Acr <br /> Owner's Name js/ Phone 16 9 S"3 4 <br /> Address .-2)3 o 4 Sr A/ L v Uj/Z S A c TD City A GAMAd <br /> Contractor's Name A P1j,'405; 4✓t6i- DRl LLfA/k License / > , Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN 17 RECONDITION /7 DESTRUCTION LT <br /> PUMP INSTAL TION L,, PUMP REPAIR /-] PUMP REPi.ACBtU3NT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DTSPOJAL FIELD CE,SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL__= ti <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r ' <br /> Industrial _ X_ Cable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing 1 2 <br /> _ X _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> � flzGS`74 � <br /> PUMP INSTALLATION: Contractor �,,,�,��.�IL"S11-f <br /> Type of Pump _.Cg, le H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUTA? .REPAIR: /-7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> •' <br /> SIGNED �14, .�� , s,ETITLE <br /> RAW LOT N REVERSE SIDE <br /> EPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY/ �( '/ ( t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE t, INSPECTION BY l- ,'( DATE 1 <br /> E H 1426 Rev. 1-74 h/75 2M <br />