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SAN JOAQUIN LOCAL HEALTH DISTRICT \ <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7;,2_ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued ;� 3-- <br /> (Complete In Triplicate) <br /> Application is tereby 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 .San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONMIle I,/ R.4 <br /> Ir o wt / e- CEN S TRACT ! <br /> Owner} �s Name Ca Phone - /— /Mrs ' <br /> Address A e- City`�'—ee:� x✓ <br /> Contractor}s Name ,_ i u, iftZ SAI, 0."" License Phone <br /> TYPE OF WORK (Check) : NEW WELL "/ / DEEPEN /_/ RECONDITION /_7 -DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�i4 PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT., PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSi <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casingji <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seali <br /> Cathodic Protection Rotary Type-of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor L [R. A <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT - <br /> / / State Work Done <br /> PUMP '.REPAIR: /. / 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 <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 TITLE <br /> (DRAW PLOT -PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , 'a <br /> APPLICATION ACCEPTED BY- _ DATE ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION j PHA F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1 <br /> E H 1426 Pow 1_7A 1/77 2M <br />