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r <br /> i Wd SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466=6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?7- I3 P 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -77 <br /> (Complete In Triplicate) <br /> t 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 Joaqui <br /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION i44 31 CENSUS TRACT <br /> Owner's NameA JT A LV Phone 0 3r" 2-z-a-V <br /> Address :� J� TR �i' • City <br /> Contractor's Name UP 1,91, - .,,� a License # ,16YZe% Phone 3 <br /> } TYPE OF WORK (Check) : -NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /�Y PUMP REPAIR / / PUMP REPLACEMENT. /_7 <br /> Other <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 f .Dia. of Well Excavation <br /> Domestic/privatef Drilled Dia. of Well Casing <br /> Domestic/public II Driven Gauge of Casing <br /> 4, IrrigationI� Gravel Pack Depth 'of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> -Disposal Other Other Information <br /> Geophysical i _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor &I tee Sa 614 �J( Rp <br /> r Type of Pump - Q�] M _ H.P. A= <br /> PUMP REPLACEMENT: / / State Work Done <br /> t PUMP .REPAIR: / / State Work Done <br /> C <br /> f 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 /> k 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 thewell in use.. The above <br /> information is true tofthe, best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED h TITLt�•.s-.�r �� <br /> II (DRAW PLOT PLAN ON REVERSE SIDE) <br /> -FOR"DEPARTMENT USE ONLY <br /> PHASE I <br /> i <br /> APPLICATION ACCEPTED BY �DATE <br /> z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHA /FIN INSPECTIO <br /> I INSPECTION BY DATE INSPECTION BY DATE <br /> - f0/- <br /> ;_ '- E H ,1+26. Rev 1-7_4- / 77 - 2M <br />