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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204){ 466-6781 <br /> �* APPLICATION FOR WELLN CONSTRUCTION OR PUMP PERMIT Permit No. 76(1- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7-7d <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the-,San Joaquin Local Health District: <br /> JOB ADDRESS/z <br /> V - CENSUS TRACT <br /> E <br /> Owner's Name6- <br /> Phone <br /> Address <br /> City <br /> `.Contractor's NameAAj� 6CLl�IS '`G� <br /> License7, Phone� ���/� <br /> STYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION / <br /> PUMP 1NSTt LATION I PUMP REPAIR /% PUMP REPLACEMENT/7 <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK' r � Q SEWER LINES FPV�IVYSEWAGE DISPOSAL„ FIELD -r — CESSPOOL'/SEEPAGE <br /> "* <br /> �J <br /> PIT <br /> PROPERTY L'IN RP$IUATEAOMESTIC WELL PUBLIC DOMESTIC WELT, <br /> INTENDED USE TYPE OF WELL �~ <br />` Industrial-m - CONSTRUCTION SPECIFICATIONS <br /> ” � ' - " - Cable 'Tool- 'Dia;of Well ExcaVati h � <br /> l 'Domestic/private �15rilled Dia. of Well�Casing <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation Gravel Pack Depth of-Grout.ISeal <br /> Cathodic Protection ��Rotary 62- <br /> Type rof4,Grout" <br /> Disposal Other � ; Other Information - a <br /> Geophysical ; Surface Seal' Ihstai_j d° : <br />`PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> `. H.P. - <br /> PUMP REPLACEMENT: State Work Doneuf <br /> PUMP '.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 'r <br /> Approximate Depth /2-49 <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 the well and notify them before putting the well in use. The above r <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED i <br /> ( L ON REVERSE SIDE) <br /> PHASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY � DATE � -,�"-" Jo' <br /> COMMENTS: <br /> P S II ROUT INSPEC N PI INAL INSPECTI N { <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev._ 1-74 V <br /> 1/77 : 9m <br />