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SAN JOAQUIN LOCALHEALTH DISTRICT oy <br /> FbR�6FFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. /� U <br /> Telephone: (209)• 466-6781 r/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?7�/G 7 <br /> k <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> > Application is Aereby 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.- 184 a d the ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .gL <br /> I n ' CENSUS TRACT p <br /> Owner's Name /V��� �7 L Y/ iqp�&V e:) Phone 9� ' �d <br /> Address �a/ � 1��� C� ,p <br /> City i� C/9hrP <br /> ' Contractor's Name Licensa' -91 Ph'VJ6 C) <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /%�-RECONDITION /_7 DESTRUCTION /_7 <br /> t PUMP INSTALLATION/ / PUMP-REPAIR /% PUMP REPLACEMENT <br /> Other- /- / <br /> DISTANCE TO NEAREST: SEPTIC-TANK r SEWER LINES .,PIT PRIVY i <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE• DONF.STIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS, <br /> Industrial Cable Tool Dia, of Well Excavation <br /> omestic/private Drilled .f Dia. of Well Casing v <br /> Domestic/public Driven- '. Gauge of Casing _ Q_ <br /> Irrigation Gravel Pack Depth of Grout.5 <br /> Cathodic Protection 1�Rotary ' Type.•of Grout / 7V 7 <br /> Disposal Other ` �Ottier Information <br /> Geophysical , - . ' 'r�-Surf ace Seal installed B <br /> PUMP INSTALLATION: 'Contractor, <br /> Type of. Pump H.P. <br /> PUMP REPLACEMENT: State Work <br /> [PUMP ,REPAIR: _ ...- / /_ State Work Done <br /> . DES:TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Ij Describe Material and Procedure <br /> ! 1 hereby agree to comply with all laws and regulations of the San Joaquin Local Health bi4trict <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNED L � () ,� TITLE �j t <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> : <br /> !APPLICATION ACCEPTED BYDATE �_ •77 <br /> ,ADDITIONAL COMMENTS: S- _7 C/ v• of cv /y <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPEC I N <br /> INSPECTION BY / �„� DATE INSPECTION BY DAT <br /> E H 1426 Rev. 1-74 ` I 1/77 2H ' <br />