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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76_77 u p <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s"a4L J6 <br /> (Complete In Triplicate) <br /> pplication is hereby made tokthe San Joaquin Local Health District for a permit to construct <br /> -3nd/or install the work herein' described. This application is made in compliance with San Joaquin <br /> County Ordinance No. C1862 and the Rules and Regulations of the San <br /> . Joaquin Local Health District. <br /> SOB ADDRESS/LOCAT�IOON.pC �p�•GO��T�l.s�o 'Ji . rl �L CENSUS TRACT <br /> 'timer's Name "LfAcEv�. CoL¢- -f �Cuc..� ! Phone <br /> Address _.1 3 3 S'U `� .� (�+ a_ City yy <br /> .ontractor's Name . a � License #/(a 2-373 Phone3A 3 <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /7 DESTRUCTION /� <br /> -J <br /> PUMP INSTLATION REPAIR S PUMP REPLACEMENT / <br /> AL " <br /> Other / / ' - • <br /> IISTANCE TO NEAREST: ; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD i CESSPOOL/SEEPAGE PIT OTHER �. <br /> , PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> a, Industrial j, '#—j— Cable Tool I Dia. of Well Excavation 1I <br /> - Domestic/private 1` _ Drilled I Dia. of Well Casing C1 <br /> Domestic/publicl} �I � Driven Gauge of Casing <br /> Irrigation I. l( Gravel Pack Depth of Grout Seal <br /> Cathodic. Proteckion 1 Rotary Type of Grout <br /> Disposal�j•�•� 1�,9` I % Other ( Other Information ` <br /> _Geophysical./ Surface Seal Installed By: <br /> F, <br /> PUMP INSTALLATION: 'Contrac -or <br /> T e of Pump H.P. O <br /> --'UMP REPLACEMENT: / / State Work Done f <br /> t <br /> )UMP .REPAIR: /;T—State Work Done <br /> DESTRUCTION OF WELL: Well Diameter !F, Approximate Depth <br /> Describe Material and Pro6b' ure <br /> f �y <br /> -i hereby agree to comply with all laws and regul ions of the San Joaquin Local Health District <br /> and the State of California pertaining to or regtlfa+ing well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will�,€urnish the San Joaquin Local Health District a <br /> JELL DRILLERS REPORT of the well and notify them jbefjore putting the well in use. The above <br /> information is ue to the be of my knowledge 4d-'belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTW ANR A FINAL SPECTIO <br /> SIGNED TITLE <br /> zl <br /> DRAW PLOT eLAN ON REVERSE SIDES p <br /> 7FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ¢e1/►J DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 376 2M <br />