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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOROFFICE' USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7�57?Ad <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED = -Date Issued <br /> , (Complete In Triplicate) <br /> Application is hereby madeto 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local Health District.- <br /> JOB ADDRESS/LOCATION Z—?36` _ O�F M D A eI p A id ' [-- CENSUS TRACT <br /> f� <br /> Owner's Name 4. P,m a —e _ __. Phone <br /> Address 1 3 _ L1? RA_c��t City cS' � <br /> Tc�eA-7-2ov <br /> k <br /> Contractor's Name aLicense # Phone 7gf �z <br /> TYPE OF WORK E WE DEEPEN T REC DITTO D STR TION <br /> (Check) : NEW WELL � DE / /$ ON, E UC /� <br /> - PUMP- INSTALLATION"/�/.. PUMP REPAIR ./ / "PUMP- REPLACEMENT -F-7 - <br /> -77 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /,�� OTHER (� <br /> PROPERTY LINE/64 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 e Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing _ /Q <br /> Irrigation Gravel Pack Depth of Grout Seal X42 <br /> Cathodic Protection Rotary Type of Grout e.V,T• <br /> Disposals Other Other Information <br /> ,—Geophysical, _r. . Surface .Seal Installed B #-WE <br /> r T <br /> PUMP INSTALLATION: Cbntracfor <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT: / /,;: State Work Done - <br /> PUMP .REPAIR: / '/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 'TApproximate 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 w <br /> information is-true to the best of. my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> �- PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED .� TITLE J �` <br /> o T ' R W PL T PLAN�ON --VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> t PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> a� � 7, <br /> ADDITIONAL COMMENTS: t Ua <br /> PHASE II GROUT INSPECTION PHASE{III/FINAL INSPECTION <br /> INSPECTION BY t DATE - - INSPECTION BY DATE <br /> 3/7 <br /> E H 11+26 V Rev. 1-74 6 2m <br />