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I <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74�-J-33 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 117 F-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. 1862 ayrdd the R_ es and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/L TION 7 Q�/ � CENSUS TRACT <br /> Owner's Name Phone <br /> Address v" ' <br /> City <br /> Contractor's Name License 4g� 37ihone_e/(4y>•77�� <br /> is <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION. /? DESTRUCTION _/_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other j_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY :tet <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 <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 <br /> PUMP REPLACEMENT: State Work D <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> W PLAN ON M9RSE SI17E) �oaat.� <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMMS: / <br /> PHASE II NS TON PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 .. . <br /> CgW76 2W <br />