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CO A, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f <br /> r Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75'-SDpJa <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued o_7 7S <br /> (Complete In Triplicate) <br /> Application is hereby made to, the Sun 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 anAl the Rules and Regulations of the San Joaquin Local Health District. <br /> _ 1 E . J i <br /> JOB ADDRESS/LOCATION +p D 140r-Atlee._ 0(1 <br /> ej4e CENSUS TRACT ' <br /> Owner's Name Phone ' <br /> Address /O© ! /Wnw r City CS qoi��2 _ <br /> Contractor's Name +wR License,# f?�'Phone . Z. -74 74 ; <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/_7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION -/? PUMP REPAIR-/)<7 PUMP REPLACEMENT %j <br /> Other, 1/ / <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 �5 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation r- Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 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. <br /> PUMP REPLACEMENT: /7 . State Work Done <br /> i <br /> PUMP "REPAIR: yLq� '�State Work Done 2.a/ 2 Ae yam <br /> { <br /> I 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." �kno ge an belief. I WILL CALL FOR-A -GROUT INSPECTION <br />' PRIOR TO GR UTING AND A FINAL INS Z CTION <br /> SIGNED `� / - TITLE rte' <br /> _ P °`2 LAN ON WtRSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , �. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHA I AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE Q4A%0 <br /> L E H 1426 Rev. 1-14 - 4/_75 -2M <br />