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Z-I <br /> AN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Lp- <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION j 670 Sh fQor,e-� CENSUS TRACT <br /> it _/ l J �'10�-3!4 �Y F <br /> Owner's Name <br /> - _c ?71 1 fa 1C -e- Phone cZ 71- (29'10 Al/f&- <br /> Address / Sd �A 9 q Y O')')-42 ��. - City ��fD L� 70 <br /> Contractor's Name Q t? Ma C I a rf o C 0 License Phone <br /> L <br /> TYPE OF WORK (Check) : NEW WELL 1W DEEPEN `/ f RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC 'TANK /So 7 SEWER LINES PIT PRIVY <br /> SEWAGE.;DISPOSAL„_FIELD,.�. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC`DOMESTIC WELL C.), <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. ,i Cable Tool Dia. of Well Excavation <br /> Domestic/private I . Drilled Dia, of Well Casing <br /> Domestic/public I'm ' Driven Gauge -of-Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal �a l <br /> Cathodic Protection” 1Rota7y' ^ �-� -7, -Type of Grout <br /> -Disposal - h �� I Other Other Information <br /> Geophysical 1 '� ,. Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor . <br /> ' Type of.\Pump - - - H.P. <br /> PUMP REPLACEMENT: / /, State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> E <br /> DESmTRUCTION,OF WELL: Well Diameter Approximate Depth <br /> Describe Material"and Procedure <br /> I hereby agree to comply withlall 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 bestoof my. know ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FI `iSPECTION. <br /> SIGNED , T TITLE <br /> D LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION . PHASE­ III/FINAL INSPECTION ; <br /> INSPECTION BY DATE j/ -/ -]4 INSPECTION BY I./4,t DATE ,� -� #' ' <br /> 3 3/76 2M' <br /> E H 1426 Rev. 1-74 <br />