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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4P6 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Y�! <br /> L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued JAN 1 6 1979 <br /> (Complete In Triplicate) <br /> ( ?lication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> � _ /or install the work herein described. This application is made in compliance with San Joaquin <br /> Ctounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ✓.d ADDRESS/LOCATION Ili .� / `- / ' <br /> .^�r� �' � �•`^`--c<L� CENSUS TRACT <br /> i ier's Name s � � i* � L Phone <br /> idress r <br /> i LZ �C`�✓ C 1�- city % / <br /> l ' <br /> itractors Name ;/r� h! % I <br /> ` ✓i License �l �� y Phone . ✓ " j%. <br /> � 'E OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7b. PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> 41 <br /> LTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> LPROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 rti <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> ift Geophysical Surface Seal Installed By: <br /> INSTALLATION: Contractor�/f `/% <br /> Type of Pump V H.P. <br /> -B? REPLACEMENT: State Work Done <br /> IMP REPAIR: / / State Work Done <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> am the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ,L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .IOR TOG UTING AN L, INSPECTION. <br /> ^NED C _ �� '+.. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 14SE I � <br /> LICATION ACCEPTED BY i " DATE 7— <br /> 4BITIONAL COMMENTS- <br /> PHASE II GROUT INSPECTION PHASE I;/FIN INSPECTION <br /> LPECTION BY DATE INSPECTION BY ATE Z— O— <br /> 1177 _ <br />