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1/ SAN 30AQtIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76—76 /o <br /> THIS PERMIT_EXPIRES' 1 YEAR FROM DATE ISSUED Date Issued B-JZ-.7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin-Local Health District for a permitto construct <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. <br /> 30B ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone'�-773- <br /> Address _/� City -422 CTef:/-� <br /> Contractor's Name �t19 �� License's a Phon&/-� <br /> -- �-7-:-��-.-ter----- -_.--��_..�;.,�-- -:.�•• �:.�- --���---�-��--��� -=..�=��-- .�-�--��--=�........,_-�._ <br /> TYPE OF WORK (Check) : NEW WELL/ 7 DEEPEN / 7 RECONDITION ./" DESTRUCTIONS/-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGZ'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ PUBLIC DOMESTIC WELL <br /> r <br /> INTENDED USE FROPER�PEIOF WELL <br /> WELL •,-- ,.,_.._._. .._.. , -.. _ <br /> ---- - -•- ---CONSTRUCTION SPECIFICATIONS <br /> Industrial !: Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing 1 <br /> Irrigation i Gravel Pack Depth of Grout Seal - <br /> ,f- <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal ► Other Other Information <br /> Geophysical. ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: f $tate Work Done <br /> V AK <br /> PUMP-REPAIR:- tate-Work-,Done - - - <br /> DESTRUCTION OF WELL: 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 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 <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. L WILL CALL FOR A GROUT INSPECTION., <br /> PRIOR TO GR UTING AND A FINAL INSPECTION. <br /># SIGNED '-y), TITLE <br /> E i1, D W4 ' PLAN''ON REV19RSE SIDE — <br /> FOR IJEPARZMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE 7 <br /> ADDITIONAL COMMENTS: r i <br /> PRASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> 4 # �. • .I' I .. - 306 Lid= <br /> E H 1426 Rev. -1�74 -" - <br />