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SAN JOAQUIN LOCALp,HEALTH DISTRICT <br /> F FOF OFFICE USE: 160l'E.•1Hazelton Ave; , Stockton, Calif. <br /> Telephone: (209)'466-67$1 �. <br /> APPLICATIONJOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �f / <br /> s <br /> THIS PERMIT. EXPI.RES 1 YEAR FROM DATE ISSUED Date Issued -9-77 <br /> (COm 1'ete 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. 1$62 and the Rule`s and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q <br /> ��!'h ! � CENSUS TRACT <br />' Owner's Name / Q� r- <br /> �idL rt Phone 0 G 2 7 2,2�/6 <br /> Address <br /> 0 5 <br /> City <br /> Contractor's Name SCiI License # Phone <br /> �I <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION f_1 DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> y Other <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 /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of`We71 Casing �' '^�^" �'^�^��—� <br /> Domestic <br />�: /public Driven ' Gauge of Casing <br /> Irrigation Grave. . Pack Depth of Grout Seal <br /> Cathodic Protection Rotary�M `' Type, of Grout <br /> Disposal Other Other- Information <br /> Geophysical {' � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor lq-< <br /> Type of Pump H..P.. <br /> .k <br /> PUMP REPLACEMENT: �/ / Szate, Work Done J <br /> NO <br /> PUMP -.REPAIR. <br /> / ./ Statel Work Done <br /> DES<TRUCTION OF WELL: Well Diameter • f 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 /> information is true to the best of my knowledge and. belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A FI L N-5,PEMVION, <br /> SIGNED 4 ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /� <br />',APPLICATION ACCEPTED BY 47 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />