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4dr �4 a / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .-/-//-7,7 <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'Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / IV ftp So_w4I ENSUS TRACT <br /> Owner's Name (,2 Q w Ct.c2. I Phone <br /> Address - - - /Otf- I►F 4 rtlyr �S C.- - City <br /> Contractor's Name License # aa'Phone B ?d7G <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION lKI PUMP REPAIR '/ / PUMP REPLACEMENT J� <br /> Other J / <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 <br /> Domestic/private Drilled Dia. of Well Casing QS <br /> Domestic/public Driven Gauge of Casing <br /> Irrigatigp 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 , a <br /> Type of Pump ,,. eA ,0, H.P. 7 Nf <br /> .PUMP REPLACEMENT: / / State Work Done <br /> PUMP '. /k/ State Work Done � v� III &d# � <br /> or <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 <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 myQWledge an belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO GP4UT-I G AND A FINAL INS?' �C \P <br /> SIGNED ,�. ITLE _ <br /> ( W <br /> PLOT PL ON RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f d- <br /> ADDITIONAL COMMENTS: 42 <br /> Z4 444 <br /> PHASE II- GROUT INSPECTION PHASE II INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 41,-t/77 <br /> 1177 2M <br /> E H 1426 Rev. 1-74 _ <br />