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b SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1bOl E,. Hazelton Ave. , Stockton, Calif - <br /> For--"OFFICE <br /> alif . <br /> EOR OFFICE USE: �J 3 rr <br /> �. Telephone: (209) 466- <br /> • 6781 <br /> permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued _ <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local Health District for a p Joaquin ; <br /> and/or install the work herein describe <br /> with <br /> County Ordinance No. 1862 andd. This application <br /> pPthe Rules and Regulatlostnofthe is SaenJoaquide in compliance <br /> ZocalHealthSDistrlct. <br /> y <br /> f 1 T CENSUS TRACT <br /> JOB ADDRESS/LOCATION / 0 Z <br /> Phone 931-259$ �. <br /> Owner's Name Adol h Toz2 , Stockton <br /> k City <br /> I Address 11711 E Ei ht Mile Road.- <br /> `' License # <br /> 76602 Phone 462-55` 7 <br /> t; <br />` Contractor's Name Clark We11 & E uipment Co • — i <br /> NEW WELL I I DEEPEN '/ I RECONDITION_ DESTRUCTION /� <br /> TYKE OF WORK (Chet } N PUMP REPAIR / / PUMP REPLACEMENT �� <br /> I PUMP INSTALLATION / / � <br /> Other <br /> NES PIT PRIVY <br /> ` DISTANCE TO NEARESTSEWER LI: SEPTIC TANK}.: CESSPOOL/SEEPAGE PIT OTHER <br /> i SEWAGE DIS'�DSAL�`FI.ELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE PRIVATE-DOMESTIC 'WELL <br /> ` TYPE OF -L CONSTRUCTION SPECIFICATIONS CQ <br /> INTENDED <br /> USE. Dia. of Well Excavation 12" <br /> I:ndu'strial` ' ;'te 'k able 1 Tao1 D.iof Well Casing ' ".&) 12 <br /> Domestic/priva " <br /> � A � Drilled, u4� .a ,, +� a. <br /> Driven Gauge of Casing •1�� <br /> D stic/public Depth of Grout Seal <br /> vl-Irrigation -------�Gx�avel�Pa•ck� P <br /> i Rotary Type of Grout <br /> Cathodic Protection Other Information <br /> Disposal Other ____ ___� <br /> Geophysical - 1 <br /> Surface Seal Installed B <br /> i <br /> t Y; ►� <br /> t � <br /> PUMP INSTALLATION: Contractor i r H.P. <br /> Type iof Pump _ <br /> REPLACEMENT: / I 'State Work Done ; ' <br /> , PUMP -- <br /> PUMP '.REPAIR: <br /> State Work Done <br /> I Iti _ <br /> Approximate Depth <br /> 'DESTRUCTION OF WELL: -Well Diameter <br /> Describe Material and Procedure <br /> ,, 1, h San Joaquin <br /> }'I hereby agree to comprict <br /> ly with all laws to orere1ations ulati�ng�welleconstruction.--With naFIFTEENlth tDAYS <br /> and the State of Cal_ifornia _perta ning¢t. - „ � , <br /> after completion of my work on a new well, I will fern 'shthe uinSathe��aellnin�use.HeThe habove <br /> rict <br /> WELL DRILLERS -REPORT of' the well. and notify" them :Before..P g <br /> information is:txue_to_the�be5t_of,�my_knowledge.. and belief.. �_I._WILL-.CA/L`L,_FO/R A. GROUT. INSPECTI N <br /> PRIOR TO G.ROU ING,AND A FINAL INSPECTION. TITLE VV,t✓ iII <br /> m F i <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �. <br /> ?APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> ` PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> 11/77 2M <br /> • \1q,�5 — <br />