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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76_7S�Ki <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date Issued 2,4 <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-1A compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name - - Phone 7�b-S� <br /> T <br /> Address (J c ] � f F�� 'Z Yom, _ --- city �r3�_� <br /> Contractor's Name License # J b V Phone b 1, S <br /> t <br /> TYPE OF WORK (Check) ; NEW WELL / 7 DEEPEN / / RECONDITION/ DESTRUCTION %�� - T <br /> � _ . , <br /> PUMP INSTALLATION/ / PUMP REPAIR -jo PUMP REPLACEMENT /7 <br /> Other k/% <br /> DISTANCE TO NEAREST: SEPTICTANK 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 ~ <br /> A Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge -of Casing . l ' <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> 4 Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> i }Done � <br />'�'PUMP7REPAIR: Work t <br /> DES•TRUCTION_OF WELL: Well Diameter App ximate Degth <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 j <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above j <br /> information is true to the best of my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG TING AND A FINAI, INSPECTION. <br /> SIGNED fjLor, K n jL, TITLE <br /> D W. P ' PLAN- ISE SIDE <br /> FO PART T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT� / + A)UFM A DATE 2_3 � I <br /> ADDITIONAL -COMMENTS: I <br /> PHASE II GROUT INSPECTION PHP,$E I AL INSPECTIOIN <br /> INSPECTION BY DATE INSPECTION BY DATE 6 <br /> + 3/76 2K-.-.' , i <br /> E H 1426 Bev. '1-74 . <br />