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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0r,_ OFFICE USE: ( 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 � r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .�' /7j 4 <br /> (Complete In Triplicate) t <br /> struct <br /> Application is hereby made to the San Joaquin Local Health District fora permit to <br /> and/or install. the work herein described. This application is made in compliance withh San Joaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �.� _C 2L- CENSUS 'TRACT <br /> Owner's Name o2/��/2 — � Phone <br /> Address �� /u• �/l�-�/ r 2i'Y1 C� City <br /> / !/L/ LicenseP.h. g`` /2Z j <br /> Contractor Name . <br /> i <br />"TYPE"QF`[n�ORK' (CYieck-�i�NE�W�LL' DEEPEN / /µ RECONDITION_/ / _DESTRi�CTZ�N /?'- <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT I <br /> { Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK ^S qSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> iINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ^�tDomestic/private Drilled Dia. of Well Casing A <br /> of Casing <br /> `Domestic/public Driven Gauge g � - <br /> Ixxigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> f Disposal Other Other Information <br /> W <br /> Geophysical Surface Seal Installed a: <br /> E PUMP INSTALLATION: Contractor <br /> Type of .Pump — H.P. <br /> PUMP REPLACEMENT / / State Work Done R. <br /> PUMP .REPAIR: / /' State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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; f wi11 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 .acid belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GEAND A FI INSPECTION. . <br /> TITLE <br /> SIGNED i; <br /> (DRAW Pt©'T PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE, Ir� <br /> APPLICATION ACCEPTED BY DATE '- ��� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE�IINALINSPECTION <br /> INSPECTION BY DATE /-' 7� INSPECTION BYDATE. A <br /> r ,A _76 � 2m <br /> TE H 1426 Rev.. 1-74 . `��'` ` y' <br /> .: <br />