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SAN 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. 7 - ,�OBrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .3D 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION q 9 /,I. & CENSUS TRACT <br /> Owner's Name A r d, Phone 9 � C// y/ Z9 <br /> I f - 91 A� <br /> Address X4+1 if City <br /> Contractor's Name rj' �^� T License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ R eCONDITION j—/ DESTRUCTION <br /> PUMP INET—ALLATION / / PUMP/ REPAIR / / PUMP REPLACEMENT /� <br /> Other / — <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELLS Well Diameter (� <br /> & Approximate Depth <br /> �0 We <br /> WDa Describe Material and Pro c dare ..v j /v .3p <br /> e 14T C C e r c <br /> T he eby 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 /> informationrue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION, <br /> PRIOR TO A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAWftff PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P -14/MAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 fes_ rir/a �;�,��.7 r..tiUCtc�,,, 3/76 2A4 <br />