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SAN JOAQUIN :LOCAL HEALTH DISTRICT <br /> FOFz':OFFIGE USE;, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�- 22-7jo <br /> f <br /> # THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued L-3a-76 <br /> (Complete In Triplicate) <br /> ' Application is hereby made to the Sun Joaquin Local. Health Distract for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui.s <br /> County Ordinance No. 1862 andR:alea and-Regulations,:of the San Joaquin Local Health District.. <br /> I _ <br /> JOB ADDRESS/LOCATION � I h CENSUS TRACT <br /> Owner's Name Phone , <br /> Address ��: �) �cfl.�SrC ' City ��� <br /> Contractor's Name ap `' v:R`�. License P; yPhone��i <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_T RECONDITION /-T DESTRUCTION /_7 <br /> ;PUMP INSTALLATION j�/ PUMP REPAIR-/ PUMP REPLACEMENT /� <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '-`- CESSPOOL/SEEPAGE PIT OTHER41. <br /> \ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED, USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , , Cable Tool " ilia of Well Excavation <br /> Dots t... 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 V <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ' Contractor ` 1 <br /> i ,Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: I ,/—/ '-State Work 'Done - _- <br /> i <br /> DESTRUCTION OF WELL: ] Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> E I hereby agree to comply with all laws 'andare'gulations -of the San Joaquin Local. Health District <br /> c <br /> and the State of California pertaining to or regulating well '•constructioh. Within FIFTEEN DAYS <br /> F '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 tolthe-best-of- my.knowledge and belief. I WILL CALL -FOR A -GROUT INSPECTION <br /> PRIOR TO GRO ING AND FIb <br /> JAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE +, <br /> f` FOR DEPARTMENT USE ONLY <br /> PHASE .I :/ <br /> APPLICATION ACCEPTED BY DATE .- ! <br /> ADDITIONAL COMMENTS: 51' <br /> PHASE II GROUT INSPECTION PHA$9,i7IyVNAL INSPE52ION <br /> INSPECTION BY �`�: DATE INSPECTION BYDATE7-4 <br /> E" H 1426 • Rev. 1-7:4 fr _�.- 4/75_ 24 <br />