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SAN JOAQUIN LOCAL HEALTH 'DIST-RICT <br /> FORiOFFICE USE: �% 1601 E. Hazelton Ave. , Stockton°;'Calif. <br /> Telephone: (209) 466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-76Otd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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.4s made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of.,.the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I , � Alvg2 CENSUS TRACT <br /> Owner's Name !V)/L Phone S6 9 aaii� <br /> i <br /> Address City I_a 2r <br /> Contractor's Name CjLicense # JJ" Phoneb �3�� <br /> Sl� <br /> TYPE OF WORK (Check): NEW WELL />T DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR /_7 PUMP REPLACEMENT 17 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK =e 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 <br /> Industrial able Tool Dia. of Well Excavation 45C <br /> Domestic/private Drilled Dia. of Well Casing _r_ <br /> Domestic/public Driven Gauge of Casing JC9 <br /> Irrigation Gravel Pack Depth of Grout Seal X5W � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information .,.,..,.._...r. \ n <br /> Geophysical Surface Seal Installed By: V� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _11�rl - .� H.P. .,. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> PES-TRUCTION 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 GROUT - G AND A FINAL INSPECTION. <br /> SIGNED TITLE �1 , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT- USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 161 h <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT!WN PHASE III/FINAL INSPECTION <br /> INSPECTION BY C, DATE / ?f 1,211 INSPECTION- BY DATE <br /> E H 1426 Rev. 1-74 , 1-74 2M <br />