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Y/ <br /> t <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx:OFFICE USE; 1601, E. Hazelton Ave. , Stockton, Calif. <br /> ` .Tele hone: <br /> l p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued <br /> 7 <br /> 4 (Complete In Triplicate) <br /> Application is hereby made to' the San Joaquin Local licalth 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. 4862 and the Rules //and.Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 f l �el/<_ CENSUS TRACT <br /> Owner's Name4, <br /> PI <br /> hone -Z <br /> Address 7 91- <br /> :, ., City iY� ._.� <br /> Contractor's Nacos c7?� ° ' .' • s �, <br /> 4,'Lieen e <br /> TYPE OF WORK (Check): NEW WELT. / DEIPEN <br /> / 7 .RECONDITTO �]" DESTRUCTION, /_7 <br /> PUMP IN9TZ 10 / �/ =PUMP R'PAIR .-� PUMP REPLACEMENT <br /> Other �' <br /> DISTANCE TO NEAREST: SEPIC TANK, SEWER! LZNES.t PIT PRIVY <br /> 5EWA DiSP .3— rte: CSS OOL/SEEPAGE PIT OTHER } <br /> Y. Y ^ <br /> PROPERTY .LINE -- PRV� P�ESTIC WELL :y_ PUBLIC DOMESTIC WELL <br /> INTENDED USETY . , WELL . I CONSTRUCTION SPECIFICATIONS <br /> Industrial �� able <br /> To Dia. of Well Excavation <br /> Domestic/private �brilled t <br /> I <br /> Dia. of Well Casing \ <br /> Domestic/public Driven ------ <br /> .�Gauge� of Casing <br /> _ L Irrigation � t - <br /> Gravel Pack Depth of Grout .Seal , <br /> Cathodic Protection, Rotary Typerof Grout <br /> Disposal Other Z Other' Information , <br /> Geophysical <br /> .. j Surface Seal Ihs,talled. By <br /> PUMP INSTALLATION: Contractor - <br /> Type .of APump- ;ems ; <br /> H.P. s <br /> PUMP REPLACEMENT: % State ork Dne e <br /> PUMP .REPAIR: /- State ,Work D ne j� <br /> DESTRUCTION OF WELL: Well DiLt r Approximate Depth <br /> Describe Material° and Procedure pp p <br /> I hereby agree to comply with d1l dawb-sand regulations of the San Joaquin Local Health District <br /> and the State of California pertaining t+o or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wel� , I ;wall kuraish the ,San Joaquin Local Health District a f <br /> WELL'DRILLERS REPORT of the well a d not�fy#`then`b fore putting.the.-well in use... The above <br /> information is true to-the•bea -offs MY kn�wled`ge-,and b" 11ef. 'I WILT, CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO T N A F'IN PjCTITON. <br /> ( RA PLOT ;PLAN ON REVERSE SID t.�.-Q <br /> ji_ FO ` DEPARTMENT USE4,ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t. . <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION . PHASE i INAL INSPECTIO <br /> fy <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H 1426 Rev. 1-74 <br />