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©� SAN JOAQUIN LOCAL HEALTH DISTRICT 4 / <br /> FOFi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7- <br /> I <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issue <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instal, 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 ;Z D T/ R P CENSUS TRACT <br /> Owner's Name -illy W I&G L Phone / 2 7 3 4 3 <br /> Address 3 3L M41AI City . <br /> Contractor's Name _ . R -rlAl P u- c-1-1J License # `c a3 Phone S7-0 .4o� <br /> TYPE OF WORK (Check) : NEW WELL ff DEEPEN -/-7 RECONDITION f7 DESTRUCTION /—j <br /> PUMP INSTALLATION / PUMP REPAIR/-7 PUMP REPLACEMENT FT <br /> —Other /% - <br /> DISTANCE TO NEAREST: SEPTIC TANK /pp�6 SEWER LINES -- PIT PRIVY �— <br /> SEWAGE DISPOSAL FIELD lc*.c> 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 Excavationi o <br /> Domestic/private Drilled Dia. jo€_Well Casing - - 6 <br /> Domestic/public Driven Gauge of Casing., l Z. <br /> Irrigation Gravel Pack Depth of Grout Seal s.a � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' , <br /> Geophysical `-Surface-Seal Installed Bv: <br /> PUMP INSTALLATION: Contractor &- ZG S7 ., ,......, <br /> Type of Pump '"" H.P. I4/? <br /> PUMP REPLACEMENT: / / State Work Done <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 /> (MAW P LAN N REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATEZ 2±76 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHASE III F NAL INSPECTION <br /> INSPECTION BY DATE 26 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 / �6 � tv- - 1"-11-12 <br /> ��y-�?� y - - - 4/75 2M <br />