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f� 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. 77_ ,RQZjz1 <br /> 'ie <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 jL_ZZ <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4)04-* ,4j i4 E /D 3 - 2-j�O--elk <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �1���� ` /, � � T�t�CC [„►y�, Phone <br /> Address �� City <br /> Contractor's Name License C6 7Y Y Phone <br /> T i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /b� PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER pQ <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS All . <br /> Industrial Cable Tool Dia, of Well Excavation _ Z o <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing -6 0 P_.e _.--, .S 5 <br /> Irrigation Gravel Pack Depth of Grout Seal -2�1 <br /> Cathodic Protection T Rotary Type of Grout <br /> Disposal Other Other Information f Ti <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump U f H.P. f <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 well and notify them before putting the -well in use. The above <br /> information is truetI6 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T6 G A CT IO <br /> SIGNED TITLE <br /> D W Pig•T 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 PHAS INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATA S <br /> l (� <br /> E H 1426 Rev. 1--74 i 3/76 2M <br />