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f <br /> Ce t �L13 SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--4a-S'p <br /> THIS PERMIT EXPIRES I YEAR FROM DATE-ISSUED Date Issued <br /> (Complete In Triplicate) , <br /> Applicatios: is hereby made to the Sar, Joaquin Local health District for 'a permit to construct <br /> andjor.install the Roark 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/LOCATION 0-10 CENSUS TRACT- <br /> ` <br /> Owner's Name r I l a h , haue <br /> a City . - <br /> Contractora Name License # 1182 W Phone V 7474 <br /> TYPE OF WORK (Check): NEW WELL -J J� DEEPEN '/_7 RECONj DITION % DESTRUCTION /_7 <br /> PUMP INSTALLATION 'LK� PUMP REPAIR 7 PUMP REPLACEMENT l7 <br /> Other /_7 <br /> -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELS.' PUBLIC DONESTIG WELL �►�} <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled_ :a r,. ,aiaoyf Wel1.Uaeing, _ <br /> inagtiz _ <br /> '/ iven _. Gauge of Casing <br /> E Irrigation .Gravel Pack. Depth of Grout Seal <br /> E <br /> -- Cathodic Protec.t_ion Rotary - Type of Grout , <br /> Disposal Other Other Information" <br /> Geophysical 'Surface Seal Installed 'By: <br /> PtW INSTALLATION: Contractor � ~ <br /> i.e.• .,, <br /> i Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ,E/ State, Work Done <br /> 'PUMP;'U State Work Done <br /> DESTRUCTION OF WELL: <br /> 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"cone truction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local. Health-district <br /> WELL DRILLERS REPORT of the well and notify them before putting..the..well- in-use..—The above <br /> j information is true to the-beet-of• leg and 6 lief. I WILL CALL R A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT N. <br /> SIGNED g , <br /> i D W LOT PLAN ON REV SIDE <br /> t <br /> OR DEPARTMT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Y' DATE Z4e /Z <br /> I ADDITIONAL COMMENTS: <br /> 1 PHASE II GROUT INSPECTION PHXSX INT/FINAL INSPECTION <br /> INSPECTION BY DATE (INSPECTIONBY DATE <br /> E H 1426 Rev. 1-74 <br />