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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 'OR.OF CE 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 MAR 31978 <br /> (Complete In Triplicate) <br /> Application is Aiareby 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 /> ti • <br /> JOB ADDRESS/LOCATION "" p CENSUS TRACT <br /> �''' ,p <br /> Owner's Name C/ �-Cr ",rte ! �� Phone "A/0^j.2!Ft ` <br /> Address f 1 �v Z;L=-� ` <br /> Contractor's Name j�-3 License': hone' "�� <br /> t <br /> TYPE OF WORK (Check) : NEW WELL;/ j// , DEEPEN /7T RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / '/ PUMP REPAIR PUMP REPLACEMENT %'r <br /> Other / / ` <br /> Qi <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEL <br /> i INTENDED USETYPE OF WELL f CONSTRUCTION SPECIFICATIONS` ` <br /> Industrial Cable-To-61 , -'Dia. of'-Well, Excavation •7 <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 R .. 'H.P, <br /> PUMP REPLACEMENT; /i,/�State Work Done <br /> _T <br /> PUMP .REPAIK: - m %% State. Work Done <br /> j,' DES-TRUCTION 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 Heals ' :strict <br /> and the State of California pertaining to or regulating we11 ''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 A GROUT INSP'EC'TION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED, TITLE AarK, <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I MAR 3, 1979 , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATA 9 4—PP ` <br /> t <br /> E E H 1426 Rev. 1-74 _ A 7.7 2M _ <br />