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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFxCE 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 /L-7-76 <br /> sS c-t.�° "vn (Complete In Triplicate) �7�I?a -p7 <br /> Appiicat on is hereby made to the an Joaquin Focal 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 , 2,",, -b', A 19 C SS VS W . CENSUS TRACT <br /> Owner's ]!Tame Phone <br /> Address _ G /9 City <br /> Contractor's Name "� �S� LP �.,� �Lr License #o?791p) Phone - <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other /-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY kN <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.REPA.IR: jy State Work Done P,02'p - <br /> ES-TRUCTION OF F 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 GROUT INSPECTION <br /> PRIOR TO &ING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> ---�._ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY z. v DATE - G <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I F INSPECTIO <br /> INSPECTION BY 91 4DATE INSPECTION BY DATEZ-L.- <br /> M1 <br /> 3 ' <br /> i E H 1426 Rev. 1-74 <br /> 1-74 2M <br />