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t:r SAN JOAQUIN t&AL�REALTH DISTRICT <br /> FOS OFFICE USE: . .601. .E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26-X06 L,J <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED Date Issued A-a5-76 <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 Joaquin <br />{ County Ordinance No. 1662 ana the Rules and Regulations o the San Joaquin Local Health District. <br /> t JOB ADDRESS/LOCATION, 1�/l .a' CENSUS TRACT <br /> ` may.. <br /> Owner's Name r Phone <br /> I <br /> Address. - <br /> ' City <br />{ Contractor's NameLicense # Phone - <br /> s <br /> TYPE OF WORK (Check): NEW WELL �/�DEEPEN j-7 RECONDITION / ? DESTRUCTION %j <br /> PUMP INSTALLATION/ / PUMP REPAIR'/_7PUMP REPLACEMENT /7 <br /> Other/ / f <br /> A._ 4 <br /> DISTANCE TO NEAREST: SEPTICtTANK j SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL,-FIELD - CESSPOOL/SEEPAGE PIT OTHER - <br />{ PROPERTY LINE -- PRIVATE. DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' I CONSTRUCTION SPECIFICATIONS <br /> j Industrial Cable_Tool_ Dia. of Well Excavation <br /> ,A:f'Domestic/private t �-Drilled -Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing . <br /> aZrrigation Gravel Pack Depth of Grout .Seal -a ---` <br /> Cathodic Protection Rotary .Type`o€ Grout _ <br /> Disposal Other Other Information <br /> Geophysical r"`—"` . <br />} € Surface Seal Installed'By: _....� <br /> PUMP INSTALLATION. Contractor f, <br /> Type .of Pump A.P. <br /> PUMP REPLACEMENT: . / State Work Done E <br /> i PUMP :REPAIR: / / State Work Done <br /> DES:TRUCTION 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 Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting-the.-well i.n..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 OUTING AND AI; INSP IaN. <br /> SIGNED - TITLE <br /> (DRAW P T PL ON REVERSE SID <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION' ACCEPTED BY - <br /> ADDITIONAL COMMENTS: ; DATE 7- -7 <br /> Z . <br /> P I RO INSPECTIONPHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE .B <br /> E H 1426 ltPv_ 1-74 V µ ��``/' "% I.IaC eM <br /> � <br />