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SAN JO QUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFI E US v ,' 1601 E. _zelton Ave. Stockton, Calif. <br /> UN 18 1976: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,6-_T 9Cj4U <br /> 4 THIS PERMITEXPIRES 1 YEAR FROM DATE ISSUED Date Issued - - el <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 Joaqui: <br /> County Ordinance No. 1862 and the Rules and Regulations of the'San -Joaquin Local Health District. <br /> f .FOB ADDRESS/LOCATION 468' A/ p2n CENSUS TRACT <br /> . alyl <br /> j, Owner's Name jQ AJ <br /> Phone , <br /> Address <br /> City , <br /> Contractor's Name ° License hone <br /> TYPE OF WORK (Check): NEW WELL . aDEEPEN.'./7-_RECONDITION /?;..DESTRUCTION /_7 <br /> PUMP INSTAL TION / PUMP REPAIR -/� PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANKe SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F PROPERTY LINE = PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �- Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public �~ Driven ,_ ` <br /> - Gauge o£ Casing V a f� <br /> _ Irrigation Gravel Pack Depth of Grout Seal 4 <br /> Cathodic Protection Rotary. - _.. y Type of Grout <br /> Disposal Other Other Information <br /> 4 Geophysical - -Surface--Seal Installed B t <br /> PUMP INSTALLATION: - Contractor .F:' . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work;Done , •r i <br />� <br /> PUMP REPAIR:' - - /7 .State•-Work�Done.w $ ,.PE 11 OF WELL: -Well Diameter <br /> _ .. �:..:�t ..> . . <br /> Approxiatate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all .lawa and regulations of the San Joaquin Local Health District <br /> cad 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..we11. in.use-... .The. above <br /> I information is true to- the-best.of my'-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIbR TO GROU ING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON.REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE O <br /> ADDITIONAL COMM Ms: <br /> PHASE II GROUT INSPECTIO <br /> PHASE IITAL INSPECTIONo <br /> INSPECTION BY DATE <br /> INSPECTION BY DAT <br /> E H 1426 Rev. 1-74 ) /75 2M <br /> '.r <br />