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If <br /> 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. iL E-5-71" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /,.7_/_ <br /> I! (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. Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> C JOB ADDRESS/LOCATION <br /> 4337 Farm St. CENSUS TRACT <br /> f Owner's Name Stockton Unified School District Phone 466-3911 <br /> I Address 1142 N.-El norado At- City <br /> k ^T <br /> Contractor's Name World Enterprises License # 265964 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUC ON <br /> PUMP INSTALLATION%/ PUMP REPAIR /. / PUMP REPLA <br /> Otherf! Le-;L - <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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial Cable Tool Dia. of Well Excavation <br /> F Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing \ � <br /> Irrigation Gravel Pack Depth of Grout Seal V <br /> Cathodic Protection Rotary. Type of Grout <br /> Disposal Other Other Information <br /> f{ <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type,of Pump _.', H.P. <br /> PUMP REPLACEMENT: . / / - State Work Done <br /> F <br /> PUMP .REPAIR: / / State Work Done <br /> f — , <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure fill w ne t c n <br /> 3 ft. below existin: grade <br /> i 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 <br /> information-is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROJMNG ANDF I PE CT N. <br /> SIGNED TITLE Co- <br /> i W Ph. T PLAN UN,RE LRSE SIDE) ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ll <br /> APPLICATION ACCEPTED BY TE^ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION AS N INSPECTION <br /> PH <br /> INSPECTION BY DATE INSPECTION BY f-' ` DATE _ <br /> co <br /> / 76 2M <br /> E H 1426 Rev. 1-74 <br />