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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> y Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ­77'/3S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/v4-77 <br /> (Complete In Triplicate) <br /> I 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. 186Z and the Rules a egul.4tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/ ATI�ON O P `�/`� CENSUS TRACT <br /> 7 <br /> Owner's N Phone <br /> Address U Cit " <br /> I r. Licensees ��73 Phon 6 �� <br /> E <br /> Contractor's Name <br /> 4 TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION DESTRUCTION <br /> ! PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Otheri / <br /> I DISTANCE TO NEAREST: SEPTICTANK SEWER: LINES PIT PRIVY <br /> SEWAGE1DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial r ` Cable Tool i Dia, of Well Excavation <br /> Domestic/private i ." Drilled Dia. of Well Casing, Q <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection fi Rotary Type of Grout <br /> Disposal ! Other ' Other Information <br /> Geophysical i # � Surface Seal Installed By: <br /> i •� X a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - � IState Work D .� <br /> r <br /> PUMP'-.REPAIR: %-'/ State Work"Done- <br /> !DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> y 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 /> jPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE rLa o w,wn _il_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 <br /> r <br /> FOIJ DEPARTMENT USE ONLY <br /> GPHASE 1 <br /> APPLICATION ACCEPTED BY / DATE 04 G 7 <br /> ADDITIONAL COMMENTS: <� <br /> PHASE II GROUTIINSPECTION P I/ NAL INSPECT ON <br /> MINSPECTION BY DATE INSPECTION BY / ATE �-- 6C e <br /> : 1/77 2M <br /> 1L?/ <br />