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} <br /> 9/ SA JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_K7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued1.-27 <br /> (Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local kiealth District for a permit to construct <br /> and/or <br /> install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1662 and the Rales and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION aL C ! CENSUS T <br /> Owner's Name W: Phone <br /> i <br /> 22 <br /> Address C7 <br /> 73 #�6 ` <br /> ractox's Name. a v,,V; License <br /> Cont h ne -7 . <br /> r <br /> 1 ' <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN , RECONDITION /7 DESTRUCTION /? ' <br /> 1 PUMP INSTALLATION/ I PUMP REPAIR-/-7 PUMP REPLACEMENT I? <br /> �". <br /> tOther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> i i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER s �, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED ,USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Ekcavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> i 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 B <br /> PUMP INSTALLATION% Contractor <br /> } Type .of Pump R.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 of California pertaining to or regulating well'-construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 /> r information' is true to the best'of- my knowledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G 'AND A F NAL. JASPECTIO <br /> SIGNED TITLE4-41 41 <br /> DRAW T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' 7 7 <br /> 4ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH FINAL INSPECTION <br /> INSPECTION BY N DATE INSPECTION BY DATE - <br /> . rr 4175 .fly! ..' <br /> - <br /> E H 1426 Rev. 1-74 Gini <br />