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4 . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76.,�61eKJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -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 instar 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 San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f a_ 2 z CENSUS TRACT <br /> Owner's Name r Phone /02 91 . <br /> Address City <br /> Contractor's Name _ License &0_ Phone4' .�i2 <br /> TYPE OF WORK .(Check): NEW WELL '/ DEEPEN '/RECONDITION /_7 DESTRUCTION /—T <br /> .PUMP INSTALLATION/ / PUMP REPAIR -/=J PUMP REPLACEMENT /7 <br /> Other F/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE' DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t Industrial A--� Cable Tool Dia. of Well Excavation � <br /> I IC.Domestic/primate Drilled Dia. of Well Casing , - <br /> 'Domestic/public Driven Gauge of Casing - -•- - <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection Rotary Type of .Grout <br /> Disposal i Other Other Information` s <br /> GeophysicalSurface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type ,of Pump H.P.•' <br /> .. PUMP REPLACEMENT: . / / State Work•Done <br /> PUM . .REPAIR: / / State Work Done x <br /> DESTRUCTION OF-WELL: Well DiameterApproximate Depth +. <br /> Describe Material aizd 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. Within FIFTEEN DAYS <br /> kafter 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..knowled ,ge, and belief. I WILL CALL 'FOR'A GROUT INSPECTION <br /> 'PRIOR TO GR TI - D A FIN INSPECTION. <br /> SIGNED t TITLE &_/Ze <br /> DRAW PLOT PLAN ON REV. SESE SIDE,�ER <br /> ' <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I J <br /> APPLICATION ACCEPTED BY AA614nDATA <br /> ADDITIONAL"COMMENTS <br /> PHASE II GROUT INSPECTION , PHASE . II FINAI. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Bim, Z4 <br /> E H 1426 Rev. 1-74 C . . !x/75 2M <br />