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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOPirOFFICE USE: !/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.7,ZgT po <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued .1-77 <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 San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION ASCI CENSUS TRACT <br /> Owner's Name diffilm OL I t44 i R n Phone -,Z2,3 <br /> Address City &SC )4k&a <br /> Contractor's Name 4' J License #,7R Phone �ao7 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN'/7 RkCONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /� PUMP REPAIR /� PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER. LINES PIT PRIVY . . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 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 Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: ;fir State Work Done aza-1 14C LL <br /> PUMP :REPAIR: /7 State Work Done <br /> E&TRUCTION 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 ajFINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ART USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPT Y l L4� , 1 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE <br /> III4EINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 - Rev. 1-74 1-74 2M <br />