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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /e 1601 E. Hazelton Ave.,, Stockton, Calif. <br /> Telephoner . (209)` 466=6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. �76- <br /> THIS PERMIT EXPIRES '1 YEAR°FROM DATE ISSUED Date Issued <br /> (.Comp-lete In Trip,Acate) <br /> Application is4hereby -made°-to the San. Joaquin Local Health District for a permit"to construct <br /> and/or install the work herein described. This appl"ication• is-made 4n compliance with San Joaquin <br /> County�Ordinance`No. 1862 land "tlie Rules andv Regulations bf"Ythe, San Joaquin Local Health District.,-., <br /> JOB ADDRESS/LOCATION y y �� 1 rQ / CENSUS TRACT ' , <br /> Owner's Name a Phone <br /> Address 7 s 8$ City EsCvL <br /> Contractor's Name <br /> License �k�G$�7 Phone. <br /> TYPE OF WORK (Check) :' NEW WELL I 'I DEEPEN / / RECONDITION I I ' DESTRUCTION /7 <br /> PUMP; INSTALLATION "/ / PUMP REPAIR" PUMP REPLACEMENT I� <br /> Other /7-7 <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 p <br /> INTENDED USE ;TYPE OF WELL 'CONSTRUCTION: SPECIFICATIONS <br /> ` Industrial :Cable;Tool.. T_.Dia.. of 'Well Excavation <br /> - Domestic/private '" ' ;^ Drilled Dia. of,';Well Casing s <br /> ..Domestic/public "Driven <br /> en <br /> o <br /> ' 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 /> r <br /> PUMP INSTALLATION: Contractor H.P. J <br /> Type of Pump - <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.-REPAIR: 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 reg ulati.ng. well'construction. Within FIFTEEN DAYS <br /> l furnish the San Joaquin Local Health District <br /> after completion of my work on a new well, I wil <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.knowl.edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. ITLE <br /> SIGNED <br /> ( D ' OT ON REVERSE SID ' <br /> F DEPART T- USE ONLY q <br /> PHASE I ���I�QT DATE <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHA III/ NAL INSPEC N <br /> INSPECTION BY DATE "~r INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 __ <br />