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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466--6781 <br /> ,�. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-gltO <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 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 `' '` <br /> I iJ s.�e _ ,� 41 � a� rdkGENSUS TRACT f�C- <br /> Owner's Name -C d to •+�- U./a]'� L7-,P.-,a`" 0Phone <br /> Address City /Ylbsei _C� <br /> Contractor's Name CA.k �� License # 11421< Phone � �,-76./%° <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP IPTSTALLATION / / FUMP REPAIR PUMP REPLACEMENT /_ <br /> Other I / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERT <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 1� ,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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. edPUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: ILe/ State Work Doneel <br /> d ✓ l <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 my kowledge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A FIN PE I n <br /> SIGNED TITLE <br /> DRAW PLAN ON nVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l-r 7- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3�7 ' <br />