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F SAN JOAQUIN~LOCAL HEALTH DISTRICT <br /> OR' OF IC USE: 1601 E. Hazelton .Ave. , Stockton, Calif. ' <br /> µ Telephone.: (204) 466-6781 <br /> .APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) �7-JZ Z <br /> Application is hereby made to the San Joaquin Local Health District for a permit to onstruct <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. 3 <br /> JOB ADDRESS/LOCATION S� � S �� �'"%�C <br /> CENSUS TRACT <br /> Owner's Name u��GL /�/t/�.f� Phone - <br /> 11363;_ ,11 <br /> Address S / s l /} L,41U,11�b _V00L), City 3-Z-'� <br /> Contractor's Name G��.'�-�tn t- --I /,t"' License Phone Sly-- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION DESTRUCTION /_7AL <br /> PUMP INSTLATION 4 PUMP REPAIR/ / _PUMP REPLACEMENT /_7 4l1 <br /> 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 j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ' Dia. of Well Excavation <br /> Domestic/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 <br /> Geophysical Surface Seal Installed By,: <br /> PUMP INSTALLATION;. Contractor z_ _v"11 <br /> Type of Pump L 4' SS H.P. <br /> J — <br />.PUMP REPLACEMENT: . / / State Work Done Z ' <br /> PUMP .REPAIR: rR / / State Work Done N� � <br /> DES<TRUCTION OF WELL: Well Diameter Approximate Depth I <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, 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 GROUTING AND A FINAh I. SPECTION. } <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> tFOR DEPARTMENT USE- ONLY <br /> PHASE I ` <br /> APPLICATION .ACCEPTED BY "` DATE 7d' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ` " wM PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> O -z�- 76 , <br /> E H 1426 Rev. 1-74 - _ µ- _ - - - 1177 ( <br />