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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 /I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7'I3 <br /> E; THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date° Issued <br /> .l°'3'77 <br /> (Complete In Triplicate) ff <br /> Application is hereby made to the San Joaquin Local Health. .District fora permit. to construct <br /> and/or .install the work herein described. This application Is made in compliance with San,Joaquir <br /> . County Ordinance No. 1862 and the Rules and Regulations of the San :Joaquin Local-Health District-. <br /> JOB ADDRESS/LOCATION Q F , <br /> ,�.,�10�/ � S� _ -s 7a����A � CENSUS TRACT <br /> Owner's Name ' D� / TOA S 7', TPhone q. -7.//*Z <br /> 'Address �f1'19 _ City. �. <br /> A _ <br /> - - - <br /> Contractor's Nam rf V License # , 73 hone 11,7 <br /> A <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/7 RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATION/ /PUMP REPAIR-/ 7 PUMP. REPLACEMENT- <br /> 0 <br /> EPLACEMENT % T <br /> Other <br /> :DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 T <br /> Industrial" Cable Tool Dia. of Well Excavation <br /> `.-t Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public.. Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ` Other Other Information <br /> Geophysical . s Surface Seal Installed 8 <br /> rte,. <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / %% State Work Done <br /> PUMP }REPAIR: / / State Work Done <br />� DE&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and. Procedure <br /> l` I hereby agree to comply with all. laws and regulations of the San Joaquin Local Health District <br /> 1 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 FOR A -GROUT INSPECTION <br /> ',PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT US ONLY <br /> APPLICATION ACCEPTED BYDATE ' <br /> ADDITIONAL COMMENTS: 1z J <br /> PHASE II GROUT INSPECTION P E TJZIYIVAL INSPECTIO <br /> . INSPECTION BY DATE INSPECTION BY E 7 <br /> E H 1426 Rev. 1--74 - <br /> 25_.__2M <br />