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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (2090 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 7y�Lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Application is hereby made to the San (Joaquin eTriplicate)In <br /> Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/I@gAT;M}. 0 � O�� CENSUS TRACT 1 <br /> Owner's Name z / ,� Phone <br /> Address <br /> City <br /> Contractor's Name r <br /> ���/7 S .� License ���-'� Phone <br /> TYPE OF WORK„ (Che.ck)_:_ NEW.WELL. DEEP-EN—./ / RECONDIT-I-ON /—/�.-DESTRUCTION./— j <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK � O + SEWER LINES S'Q Y- P.IT PRIVY <br /> SEWAGE DISPOS� U ELD CESSPOOL/SEEPAGE°,PIT/QU (—OTHER " <br /> PROPERTY LINE=•°PRIVATE DOMESTIWEI;L ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `" , CONSTRUCTION SPECIFICATIONS <br /> Industrial �,,3 <br /> Cable Tool j,,,;, Dia: -of„We:11 Excavation /2— <br /> Domestic/public <br /> � <br /> 7- <br /> Domestic/private Drilled Dia, oftWell�� Casng S — ` <br /> Domestic ublic `4 ”` <br /> /P Driven �. •; Gauge of Casing L, <br /> Irrigation .-Grave1 !P:ack ` , �bepth of Grout Seal <br /> Cathodic Protection Rotary , Type of .Grout F fF <br /> Disposal Other `' '" 7. Other Inforinationo / r <br /> Geophysical r Surface Seal�Installed B S <br />?UMP INSTALLATION: Contractor <br /> Type of Pump <br /> F .' Z H.P. <br />'UMP REPLACEMENT: / / State Work Done �a <br />'UMP :REPAIR: / / State Work Done <br /> EESTRUCTION OF WELL: Well Diameter � <br /> Approximate Depth -;", <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well "constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> FELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> nformation is true to the best of my knowledge and belief. I WILL-CALL FOR A 'GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION <br />',IGNED �--TITLE16�� <br /> PfOT PAN ON REVERSE SIDE) <br />'RASE T FORD ARTMENT USE ONLY 4K L4� <br /> PPLICATION ACCEPTED BYZ4=2�46 DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I/ NAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY ATE V'717,17Z z <br /> E 1426r 1 r <br /> Rev. 1-74 �/7 � - 2M k <br />