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[/'/} SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: W 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No. .Z,7'`2A28. p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued : -7 - r <br /> i (Complete In Triplicate) <br /> Application is hereby made toithe 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.,i <br /> County Ordinance No. 1862 and 'the Rul nd Regulatio of the San -Joaquin Local Health District <br /> JOB ADDRESS/LOCATION �v /e ENSUS TRACT <br /> Owner's NamPhone "1 � <br /> f <br /> Address u City / <br /> Contractor Name ��_ l�� �� �7/� LicensePhone- <br /> -TYPE OF WORK (Check)-;-.- NEW-WELL '%� DEEPEN-./ RECONDITION / DESTRUCTION /7 , <br /> PUMP INSTALLATION PUMP REPAIR % I PUMP REPLACEMENT %7 <br /> Other l 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY, r <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, s ' � <br /> Domestic/private Drilled- Dia. of Well Casing t, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Lj <br /> Cathodic Protection Al SRotary #, 4 , Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / ; State: Work Done <br /> PUMP .REPAIR: / / State' Work Done <br />"AES-REL -OF-WELLI—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 Dlatrfct <br /> and the State-of California pertaining to or regulating well"construction. Within FIMEM DAYS. � <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health Dfstrice <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 o£ my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTIE. <br /> PRIOR TO GRO TING AND..A. FINAL INSPECTION. <br /> SIGNED TITLE .;':,r <br /> DRAWMM PLAN 'ON 1tSE SIDE p.? <br /> c FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION.ACCEPTED BY -- - - DATE <br /> ADDITIONAL COMMTS: `+ <br /> PHASE II GR= .INSPECTION P S fF INSPECTION` <br /> INSPECTION BY, INSPECTION B DAVE - <br /> 3/76. <br /> E H 1426 Rev. 1-74 <br />