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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 0! <br /> Telephone: (209) 466-6781 7 7' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `77-Y8 few <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued b.�,�" 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 Joaquin <br /> County Ordinance No. .1$62 and the Rules and Regulations of the San Joaquin Local Health District.? <br /> JOB ADDRESS/LOCATION _ 2_C?/S' GARIOE E RQ, -57-eCkroAl_ CENSUS TRACT <br /> Owners Name /100/-S mgte I Phone <br /> Address / GA12 EN ER PA, City 740GltToN- <br /> Contractor's Name &0 G fJ P AIC-, License # Phone'?-,/T-RV 7 <br /> s TYPE OF WORK (Check) : NEW^ WELL '/9 DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 -, <br /> ` PUMP INSTALLATION REPAIR %/ . PUMP REPLACEMENT /7 <br /> +' / / <br /> Other � <br /> DISTANCE TO NEAREST: SEPTIC TANK 30QF SEWER LINES 3po/ - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> a Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicDriven Gauge of Casing 0 C- <br /> X 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 AICA G K 0_VA1)0Ad <br /> { Type of Pump _ �U R/Ad,E `x H.P. <br /> f PUMP REPLACEMENT /_7 State Work Done <br /> PUMP -REPAIR: /7 State Work Done <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 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 /> b PRIOR TO GROUXING AND A F NAL INSPECTION. <br /> SIGNED .:"42"ZL,�ZQ4 'ON TITLE <br /> DRAW PL T PLAN SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Is <br /> APPLICATION. ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ! PHASE II GROUT INSP CTION PHASE III/FINAL INSPECTION <br /> F INSPECTION BY DATE INSPECTION BY Gd DATE 3- It <br /> 3/76 2M <br /> E H 14.26- -- Rev. 1-74 <br />