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_ 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRJCr <br /> FOfi OFFICL USE: 1601 C. Hazelton Ave., Stockton, Calif. <br /> Telephone: (205) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION fia PUi1P PERMIT Permit, No. 76- 717 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued le,-J4 -76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This applicatiun is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of tie San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION :��/%,, -� . -�-� - ;'•y CENSUS TRACT <br /> Owner's NameII��',_. ,y-,,,.,r, f / Phone / <br /> Address I Z'f� JAIUy.ST!�1[� 2/f��/7T GityylJ.�ls� .. ��Cs-n afs.. <br /> Contractor's Name 4� ! v i Y - "< License 0Phone <br /> TYPE OF WORK (Check): NEW WELL /yT DEEPEN /7 RECONDITION /_7 DESTRUCTION y <br /> PUMP INSTALLATION / / PUMP REPAIR /—/—PMI RBPLACEMEN /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK LZ(, . SEWER LINES PIT PRAY <br /> SEWAGE DISPOSAL FIELD ___ CESSr iOL/SEEPAGE PIT OTHER <br /> PROPZTVN LINE - PRIVATE DOMESTIC WELL —_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation r` <br /> Domestic/private Drilled Dia. of Well Casing <br /> Y Domestic/public Driven Cauge of Casing /12 q <br /> Irrigation Gravel Pack Depth of Grout Seal: <br /> Cathodic Protection —� Rotary Type of Grout <br /> Disposal Other Other Information. l� <br /> Geophysical Surface Seal Installed By: ATFv_z <br /> PUMP INSTALLATION: Contractor <br /> Type of. Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PIRAREPAIR: /_7 State Work Done \� <br /> Ep MUCTION OF WELL: 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 construction. W:thin 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 <br /> information is true to the beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO C TING AND .4 FIN I SPECIION. <br /> SIGNEDTITLE �=' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DFPART.D:NT USE ONLY <br /> PILOSE I <br /> APPLICATION ACCEPTED BY _ DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE. III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />