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-•- .' : �� ,, SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> F rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . <br /> Telephone-. .p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-. 74/-,�fjo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g-,4t-�6 <br /> (Complete In Triplicate) <br /> Application is herebymade to the San Joa uin Loca1 �H <br /> q .. ealth District for ap ermit to construct <br /> and/or_,install the .work. herein described. . This application is made in compliance with San Joaquin' <br /> County Ordinance No. 1.862 and the Rules ,:and Regulations of the- San Joaquin-.Local Health District. <br /> JOB ADDRESS/LOCATION. SE 1/4 NW 1/4 Sect. .35 T3S.RSE CENSUS TRACT w <br /> I - <br /> Owner's Name Tracy Golf & Country Club Phone 835-.9890 <br /> I <br /> i <br /> Address— P.O. Box 277 - _ ..,.. <br /> ,:. _ . .w -- - City - -Tracy.... _ <br /> Contractor's Name Western Well Drilling Co., Ltd. License # _25182 ityPhone408/295 <br /> TYPE OF WORK (Check): NEW WELL ,/-7 DEEPEN /-T RECONDITION Iv7 DESTRUCTION /7PUMP INSTALLATION / / PUMP REPAIR /%/ PUMP REPLACEMENT <br /> Other E7 ' <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 �I <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public �,. .._ _ Driven Gauge of Casing <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 western Well Drilling Co., Ltd. <br /> Type of Pump Turbine <br /> H.P. # <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-'REPAIR: 7'°'_S'thte Work=Done <br /> ES;TRUCTION 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 Skate of California'pertaining to or-regulating well constructian.—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 o ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO A FINAL INSPECTIO ,. <br /> SIGNE J � TITLE Vice President. 7/23 , .6 <br /> !E (DUEP -PLAN ON REVERSE SIDE - � . <br /> .FOR. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GROUT INSPECTION PHASE INSPECTION <br /> INSPECTION BY DATE INSPECTION BY '+ DATE <br /> E H 1426 Rear. 1-74 <br /> 1-74 2M <br />