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14/2 &-t,� <br /> ­ <br /> SAN <br /> USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> + PFO 1601 E. Hazelton Ave. Stockton Calif /� <br /> r <br /> Telephone : (209) 466-6781 /!OLZ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�Z-Z(,/� <br /> _ _ � THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �1 <br /> } t/t--G_f 7 �tiC0�+1` _ �" E.2!!� (Complete In Triplicate) 257 <br /> I' <br /> Application is here`6y 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 ulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q v S - <br /> 4 M 1 to oma! /I�CENSUS TRACT <br /> i <br /> Owner's Name 91d Phone <br /> Address - <br /> � city <br /> IV <br /> Contractor's Name License Phone�l�_/ � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 <br /> { PUMP INST LATION / / 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 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia, of Well Excavation <br /> t Domestic/private Drilled Dia, of Well Casing �— <br /> Domestic/public Driven Gauge -of Casing <br /> Y Irrigation ` Gravel Pack :Depth of Grout Seal rT <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br />} PUMP INSTALLATION: _Contractor <br /> Type of Pump — - H.P. /� �`�@h7� <br /> j -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> r 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 G OUTING 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 f -73 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT'. ON PHASE 'I/FIN INSPECTN <br /> INSPECTION BY DATE INSPECTION BY JIJ DATE I t <br /> OF <br /> ,.,- E H 1426 Rev. . 1-74 6/77_- 2M a <br />