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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 k5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-, <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -33P--22 <br /> (Complete In Triplicate) „_ f <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to construct I <br /> and/or install the work herein described. This application is made in compliance with San Joaquin . <br /> County Ordinance No. 1862 andithe R les and Regulations of he San Joaquin Local Health District. <br /> .ro <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> eny <br /> Owner's Name _ Phone -� <br /> Address DCit <br /> 7 <br /> �r f <br /> Contractor's Name License Q a Phone <br /> r <br /> TYPE OF WORK (Check) : .NEW WELL/ DEEPEN/_/ RECONDITION 4 /, DESTRUCTION <br /> PUMP INSTALLATION 1,,(,4 'fP REPAIR,'/, REPLACEMENT 7-7 <br /> 'Other <br /> ” <br /> DISTANCE TO NEAREST: SEPTIC STANK 60 SEWER LINES j'0-t> - PIT PRIVY ------— , <br /> SEWAGEjDISPOSAL FIELD D'c�// CESSPOOL/SEEPAGE PIT��OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br /> Industrial t� Cable Tool Dia. of Well Excavation-,.,- <br /> g estic/pr ivate F Drilled Dia. of Well Casing '— <br /> Domestic/public <br /> asingDomestic/public I Driven Gauge of Casing x, a <br /> ' Irrigation 'r 1 Gravel"-Pack Depth of Grout Ser • _ _ <br /> _ Cathodic Protection -i4,,,:- YtzStary ,Type of Grout -- <br /> l Disposal Other +:Other Information r c" <br /> 4-A Geophysical face Seal Installed-By: <br /> or <br /> ':. 4..4 <br /> I� PUMP INSTALLATION: Contractor P �--LA <br /> i TYPe of Pu H.P. ., <br /> ;PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR;---,r- - / /7—S to te'Wo-rk'Done' <br /> a <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-Loc4i Health District a <br /> ' WE DRILLERS REPORT of t wetland notify,,them before putting the .well in use. The above <br /> v inf tion is true o b st o my4-knowledge and belief. I WILL CALL—FOR A GROUT INSPECTION <br /> PRIOR ROUTING AL ligFIXT40N. ` .Y <br /> SIGNED - - �" TITLE <br /> DRAW PLOT' PLAN ON"RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> P GRO INSPECTION PHAS I FINAL SPECTTON <br /> h INSPECTION BY BATE INSPECTION BY ATE 7. <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 i : s <br />