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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. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Isstzed2:--i - , <br /> i (Complete .In Triplicate) <br /> Application isherebY �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 Toaquin <br /> County Ordinance No. 1.862 aril the Rules and Regulations of the San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION F 3, & iY CENSUS TRACT. . <br /> Owner's Name ! Phone <br /> r ibv G4J ra.r° i _a�.r?�r e.e .�r Grs___ _ + G <br /> Address 393S X7 Aldlv City <br /> Contractor's Name ,� License �� Phon . <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPFN / / RECONDITION '/' / -"DESTRUCTION'/-7 <br /> PUMP,,jINSTALLATION Its PUMP REPAIR / / PUMP REPLACEMENT / / <br /> Othet <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT .&fftf OTHER} <br /> PROPERTY LINE/W PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE A -.TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of 6Iell Excavation L <br /> Domestic/private Drilled Dia. of Well Casing" N ,' , s <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 /> kms. Geophysical " Surface Seal Installed By: <br /> C- TVI'--17-S-Al Z nz&fg- I X-V je I OA 0, K <br /> PUMP INSTALLATION: -°Contractor <br /> Type'of Pump H.P. <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 off California°. pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion' ofmy work on a new well, I will furnish the San Joaquin Local Health Distr.ict, a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in use. The above <br /> tr <br /> information is ue to the best of �my kriowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND !A FINAL INSPECTION'-,)' <br /> . SIGNED _11 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI _ ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ;. DATE <br /> C ADDITIONAL COMMENTS: { 1 <br /> PHASE II'GROUT: INSPECTION PHASE III/FINAL INSPECTION s <br /> INSPECTION BY t r-t DATE INSPECTION BY DATE - <br /> .. •r s <br /> r 6/77 - 2M <br /> E H 1426 Rev. , 1-74 I - <br />