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FOH;OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S&LA71,) , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued fL1r 7 ji <br /> (Complete In Triplicate) z©_3 —03,0--61 <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. <br /> JOB ADDRESS/LOCATION CIL <br /> fY C- Z.442 WOODCENSUS TRACT <br /> t <br /> Owner's Name U a 1pr Phone <br /> Address <br /> City 701 <br /> Contractor's Name ,G License Z 6eZ. Phone -.e_ ` <br /> TYPE OF WORK (Check): NEW WELL "/ DEEPEN /_7 RECONDITION <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7—PUMP EREPLACTEMENON � <br /> Other /17 <br /> DISTANCE TO NEAREST; :"SEPTIC TANK ?L— SEWER LINES . -.PTT_PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTHER <br /> PROPERTY i LINE - PRIVATE DOMESTIC WELL" .PUBLIC _D'OMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _y Industrial I ! -Cable.Tool Dia. of Well Excavation <br /> Domestic/private DrilledDia. of Well Casing - ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation g �� Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout 1 r <br /> Disposal Other Other Information r <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor ��- <br /> Type of ,Pump ' <br /> H.P. <br /> PUMP REPLACEMENT: i " " E <br /> / / State Work Done <br /> PUMP 'REPAIR: � k <br /> / / :State Work Done . <br />)ES4TRUCTION OF WELL; Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> I � <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> knd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> tfter completion of my work on a new well, I will furnish the San Joaquin Local Health District' <br /> TELL DRILLERS REPORT of the well and notify them before putting.. the..well in.use..:. .Thd above <br /> Information is true to` the•best•of- my"knowledge and beliefI WILL CALL.-FOR A"GROUT INSPECTION <br />'RIOR TO �UT�ITNGNDA �A�L�.INSPECiIO�N �. �� � <br /> iIGNED TITLE <br /> {DRAW PLOT_PLAN_ ON REVERSE SIDE - <br />'RASE T - <br /> FOR DEPARTMENT USE ONLY <br /> *n • . <br />►PPLICATION' ACCEPTED BY a <br /> LDDITIONAI; COMMENTS: "_. _. - _— <br /> - DATE:- 7� <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br />;NSPECTION BY DATE. INSPECTION BY DATE <br /> E H. 1426 Rev. y1--74 _ } <br /> i./?o oiu { <br />