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SAN JOAQUIN LOCAL HEALTH- DISTRICT 6/7- <br /> FOE QFFICE USE: 8 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,3 6 E <br /> 77-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y-13-77 <br /> (Complete 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/k@eATMN- " CENSUS TRACT <br /> Owner's Name Vet L41VIIIPhone <br /> Address 41^-A City <br /> Contractor's Name LicenseJ7���Phone ,�r' <br /> .. i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ / RECONDITION /_/ DESTRUCTION f-J <br /> Y PUMP INSTALLATION/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> -- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESIT PRIVY <br /> SEWAGE DISPOSALFIELD Z04)f-CESSPOOL/SEEPAGE PIT D t-eTHER <br /> PROPERTY LINEZ PRIVATE DOMESTIC WELL *UBLIC DOMESTIC WELT <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS j <br /> Industrial Cable Tool Dia. of Well •Excavation ZZ <br /> Domestic/private Drilled Dia, of Well Casing 6 <br /> Domestic/public Driven Gauge of ,Casing / Z ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal f Other Other Information <br /> Geophysical s Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Q 0 ly 04 it J4 <br /> Type of PumpH.P. Z_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: ,. / / State 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 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 FINAL INSPECT <br /> SIGNED LE <br /> DRAW PT T PLAN f N REVERSE SIDE) " ' } <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA I G OUT INSPECTION PHAS TII/ INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 77 <br /> 3/75 2M <br /> E H 1426 Rev. 1-74 s <br />