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I J SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: y '1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77-11ki] <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued F L� ) 7 <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. 1862 and the Rule and Regulations o f he San oac�in�cal alth�8 �trzct <br /> j - - -G !�� <br /> JOB ADDRESS/LOCATION CENSUS TRACT _ <br /> Owner s Name <br /> )Phone c���'• �� � <br /> Address 3 Cityel <br /> -' <br /> Contractor's Name License # _W/4Phone rn 3 F <br /> d• <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 �. <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:`` Contractor <br /> aZ _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done �u.l d <br /> `C 1, <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 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 GRO ING AN NAI, INSPECT ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY DATE UU 7 I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - f <br /> R A 7/.•79 n___ 1 '7 1. b/ _ 2M <br />