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- <br /> Z_17 <br /> ' ;;,, SAN JOAQUIk LOCAE. HEALTH DISTRICT �Ge�,d <br /> FGR��uilICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> s <br /> Telephone:: <br /> P- (2O9) 466-b7$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 27- (,(J <br /> s THIS PERMIT: EXPIRES 1 YEAR FROM DATE ISSUED Date Issued_ -� 77 <br /> t- (Complete In Triplicate) <br /> Application is' 1`ierebmade 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 Rues and Re ulati n of the San Joaquin Local Health-:Distr#et. - <br /> �6/ �• W X125- ' l <br /> JOB ADDRESS/LOCATION <br /> - � CENSUS TRACT <br /> Owner's Name <br />' Phone <br /> Address , <br /> City <br /> Contractor's Name ' Ar <br /> icense # Phone - <br /> i <br /> �A <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/% RECONDITION /_� DESTRUCTION <br /> z PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> LSEWAGE'DISPOSAL FIELD CESS OO /SEEPAGE PIT OTHER <br /> ®5 <br /> PROPERTPIT PRIVY <br /> Y LINE '-- PRIVATE DOMESTIC WELL WELL <br /> PUBLIC DOMESTIC <br /> INTENDEDfUSE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> _ Domestic/private Drilled�`_•� - ,. ' Dia. of Well Casing ;r <br /> _:;-. �,-Dome.s•tatc/public 1 �*--�� -:� <br /> riven���- °.uGauge o. -Casing'" <br /> Irrigation '� 3Gravel 'Pack bepthtrof Grout Seal <br /> Cathodic Protection <br /> - Rotary Type of,Grout <br /> Disposal t Other <br /> Geophysical �' � ,' <br /> O'ther'-Irifor�nation' <br /> .. '�--, � � <br /> Surface Seal Installed B <br /> FUME INSTALLATION:; Contractor <br /> Type of Pump - <br /> s H.P. <br /> PUMP REPLACEMENT: , / / State Work Done 4 , <br /> PUMP -REPAIR: / / St'a`te Work-Done <br /> DESTRUCTION OF 'WELL � r Z—As Y - �"i/ vt <br /> Mte' D Approximate o r� CJ Depth <br /> e/p�tht..�� <br /> t_ <br /> rProcedure <br /> P- y with a1 aws d regulations o the San oaqu n Loca Health D strict <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 i <br /> information is true Eto the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION , <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED' TITLE <br /> DRAW_ <br /> OT-PLAN_ON-REV.ERSE_SIDE <br />' FOR D+ ARTMENTOUSE ONLY <br /> a_ <br /> PHASE I <br /> APPLICATION ACCEPTED BY z <br /> ADDITIONAL COMMENTS: DATE <br />` PHA GROUT INSPECTIO { <br /> PHAS II/FINAL INSPECTION <br /> INSPECTION BY TE �O INSPECTION BYDATE 7,v <br /> ;' ... �. -7 <br /> _/ T. - <br /> E1426 . � <br /> Rev. 1-74 A- 1177' �` <br />