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SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> FOE"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: <br /> alif. - <br /> Telephone: (209) 466-6781 permit No. r3_lam <br /> APPLICATION FOR WELL CONSTRUCTION OR pump PERMIT 76-//age <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 j <br /> (Complete In. Triplicate) i <br /> Application is hereby made to thuThisLocal <br /> app-1Fication isealth tmade infor <br /> compliance tuwith SanJoaquin <br /> and/or Install the work herein described. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distxict. <br /> ' Cf� �! c A�'i CENSUS TRACT <br /> JOB ADDRESS/LOCATION �d <br /> Phone �l3 <br /> I Owner's Name <br /> City <br /> Address _ <br /> V, - <br /> L-icense 1? hone <br /> Contractor's'Name M n D <br /> DEEPEN I I _RECONDITI6N F7 DESTRUCTION /� <br /> TYPE OF WORK- (Check) : NEW WELL / <br /> i PUMP INSTALLATION /_V-7715P REPAIR PUMP REPLACEMENT /? <br /> .� Other <br /> DISTANCE ,TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE.PIT . I OTHER <br /> ._-__PROPERTY LINE - PRIVATE�D(7MESTIC WELL <br /> '"`PUBLIC DOMESTIC WELL <br /> INTENDED USE 1 TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ <br /> I dustrial '�* able Tool %*,pia. of Well Excavation �. <br /> Domestic/private � Drilled <br /> Dia:---of- Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> i F . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> RotaryType of Grout s - <br /> Cathodic Protection i '- <br /> Disposal` ' er _ Other Information'. <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: - Contractor <br /> _ Type of Pump , A <br /> jr <br /> yState., Work Donees ; <br /> PUMP REPLACEMENT: - /_77+ !` <br /> I PUMP REPAIR <br /> - r`= �/ State Work Donee <br /> . : <br /> �� Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter f <br /> Describe Material and Procedure <br /> I hereby g <br /> b agree to comply with all laws and regulations of the San, Joaquin Local-Health District <br /> i <br /> k and the State of California pertaininto ri willlfAYS <br /> urnishethe cSan tJoaquin.L calhHealth District a <br /> i after completion of m,work on a new well, in above <br /> WELL DRILLERS REPORT`oft,the well andel notify <br /> yethem before <br /> puttyng'tl WILL CALL FOR AeGROUTeINSPECTION <br /> information is true to the best o MY <br /> knowledge <br /> TO GROUTING AND A NAL INS CT TITLE <br /> DRAW PT PLAN ON RE ERS'E SIDE) <br /> ! FO DEPARTMENT USE E ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: _ <br /> ` PRASE II GROUT INSPECTION PHASE III/FINAL: INSPECTION <br /> INSPECTION BY i DATE_ <br /> 'INSPECTION B DATE - <br /> 3/76 2M <br /> E H' 1426 Rev. 1-74 <br />