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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI E USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v _ I Telephone: (209) 466-6781 /� -I <br /> 71 -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i <br /> mai 4 <br /> � . . SEC' 2.8 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issue 19 <br /> (Complete in Triplicate) <br /> Application is hereby made tojthe San Joaquin Local Health District inrcomplancetwithnSanJoaquin <br /> and/or install the work herein described. This application is <br /> County Ordinance No. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION F78q 5 <br /> Phone <br /> Owners Name ! <br /> City <br /> Address <br /> 1 i 1�,��1 l.� { D� _ License g-IR Phoney 1I •�! <br /> Contractor s Name <br /> TYPE OF WORK (Check): NEW� WELL DEEPEN/ I RECONDITION Pump I DESTRUCTION /7 <br /> l � <br /> PUMP INSTALLATION / / PUMP REPAIR I:I <br /> other ►1 ! <br /> i <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES/0 0 A)PIT PRIVY _ <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTABR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE :TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS � <br /> Industrial 1 Cable Tool Dia. of Well. Excavationr• 'L <br /> Domestic/private 1 <_ Drilled Dia. of Well Casing <br /> Domestic/public zl Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Type of Grout 3 x TT <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed B <br /> 1 PUMP INSTALLATION: Contractor <br /> H.P. ` <br /> Type iof Pump r <br /> I PUMP REPLACEMENT: . % / t. State Work Done <br /> PUMP .REPAIR: / / ' State Work Done <br /> Approximate Depth `` <br /> DESTRUCTION DF WELL: Well Diameter - t <br /> Describe Material and Procedure r <br /> I .hereby agree to comply with all laws and reguti <br /> laons of the San Joaquin Local Health Hfstxict <br /> and the State-of California pertaining to or regulatini hethecSantJoaquin�Local HealtWithin hTDistEEN riet a <br /> after completion of my work' on a new wall, I will fernThe above' <br /> i WELL DRILLERS REPORT of the well and notify them before putting the CALLwell in use. <br /> information is� true to the,best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION... <br /> r PRIOR GROUT ANDA FI , INSPECTION. TITLE <br /> SIGNEDI.., <br /> pi,AN 'ON EZtSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATF <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: P SE II FINAL IN <br /> PHASE II GROUT INSPECTION INSPECTION B <br /> INSPECTION BY DATE <br /> 3 76 2M <br /> E.K 1426 Rev, 1-74- ; . <br />