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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOF OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> II Telephone: (209) 466-6781 <br /> II APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7e- x'23 p <br /> I� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 3 <br /> f Application is ,hereby made to the San Joaquin Local Health District for a permit to construct <br /> i 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 Regula-tions of the San ,Joaquin Local Health District. <br /> JOB ADDRESS/LOII ATION =G'7 G .S' cJ /t�'/eft.� ��/[ CENSUS TRACT <br /> Owner's Name �II ;i � '77 Qft-+ r G`>-"� Phone <br /> Address _ �� 6 s ,/movie City <br /> Contractor's Name License #/- ].hone 4721 tS <br /> I II. r°• <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR Y/ PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL 0l <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C� <br /> l Industrial Cable Tool Dia, of Well Excavation <br /> I Domestic/private Drilled Y A Dia. of We11.Casing <br /> Domestic/public - Driven- ' Gauge of Casing <br /> Irrigatilbn Gravel Pack Depth of Grout Seal <br /> CathodiclProtection Rotary Type of Grout <br /> Disposall Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> If , <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. 1.� <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: I State Work Done -! r '� <br /> I DESTRUCTION OF WELL:-: Well Diameter Approximate Depth <br /> q` 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 Statellof 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 /> _i WELL DRILLERSjjREPORT`of the well and notify them before putting the well in use. The above <br /> information is true to the best of my°knowled belief. I WILL CALL FOR A GROUT INSPECTION <br /> r PRIOR TO GRO TING AND,A FINAL I SPE ` ITLE <br /> SIGNED �1. <br /> DRA PLOT PLAN ON RIWERSE SIDE) <br /> L V FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> II DATE 9- 7� <br /> APPLICATION ACCEPTED BY �' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYI DATE INSPECTION BY DATE -/�$" <br /> 1 3/76 2M <br /> E H 1426 j Rev. 1-74 <br />