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/0 le ao SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOH -OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � a <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) D-,", --C)L&>--zz <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION m✓ p �])'��,,I CENSUS TRACT <br /> Owner's Name 7= Phone <br /> Address _ f �'' �� <br /> City <br /> Contractor's Name License # 'vj Phone -*74,76 <br /> or <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /_7ALi <br /> PUMP INSTLATION '/ / PUMP REPAIR Z/ PUMP REPLACEMENT 17 . <br /> I Other/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 0�1 <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT . OTHER �3 <br /> „, 4l <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '. PUBLIC DOMESTIC WELL (�{ <br /> i' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial I Cable Tool Dia, of Well Excavation <br /> —x Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/putAic I. Driven Gauge of Casing <br /> Irrigation ] Gravel Pack Depth of, Grout Seal J <br /> Cathodic Protection I Rotary Type of Grout a <br /> Disposal 1. Other Other Information j <br /> GeophysicalSurface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type cf Pump H.P. <br /> .PUMP REPLACEMENT: /%,', State Work Done <br /> PUMP .REPAIR: / State Work Done �1 _.� Qr,�yy u .s`,• -0- J <br /> a <br /> DESTRUCTION OF WELL: Well`DiameterF <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to 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 I <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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE 0 <br /> SIGNED - TITLE' rrsr. <br /> PLAN 'ON EVERSE SIDE) <br /> 0 <br /> PHASE I EPARTMPNT USE ONLY L <br /> APPLICATION ACCE B F}L 4LSIE� DATE 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA§X III ,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /A-7 <br /> E H 1426 Rev. 1-74 ! ` 3/76 2M, <br />