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< I � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFVCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7].•/p gyb0 <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,Z �7 <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 application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of. the Sap Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / A-0A-_j, / Am, le �3r�4mjd CENSUS TRACT <br /> I <br /> Owner's Name �C9GtSGt. �i7j S Phone <br /> Address �1" -�_ C�LD�'d ZGm 44 $ City V 'y"`, <br /> Contractor's Name J .,� License / -74r hone � � <br /> —- -- ; <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PU'KP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY T <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY LINIF - PRIVATE.. DOMESTIC WELT, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tuol Dia, of Well Excavation _ V <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grouti <br /> Disposal Other Other Information <br /> Geophysicl_1 Surface Seal Installed By: !h <br /> 1 <br /> PUNII' INSTALLATION: Contractor <br /> Type of PumH.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP REPAIR: kl State .Work Done <br /> DESTRUCTION 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 i <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 <br /> information is true to the best of'my knowl-edge and bel. ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AND A 'INAL 13NSPECTI( . <br /> SIGNED <br /> (D P P N REVEnE SIDE) <br /> fFIV DEPARTMENT USE ONLY <br /> PHASE I DATE C `/y ' 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE, III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f DATE <br /> o/77 - 2M <br /> E H 1426 Rev. 1-74 <br />