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SAN JOAQUIN LOCAL� HEALTH DISTRICT <br /> F'ORrOFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> 1 APPLICATION. FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- X93 <br /> I <br /> THIS PERMIT EXPIRES I, YEA.R..FROM DATE ISSUED Date Issued <br /> is (Complete in Triplicate) <br /> Application is hereby trade to the San Joaquin Local ,Health District for a permit to construct <br /> 1 and/or install the workhefe3n described. This appl•i�cation is made in compliance with San Joaquin <br /> County Ordinance No. A62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 11 .112 CENSUS TRACT <br /> i Owner's Name Marg Phone <br /> Address i3�{� I�; <br /> � .�� . City c <br /> Ij <br /> Cat'ractor's Name 1} -4 go 11,4 'VM QC' , License # Phones; -3 <br /> ul <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/_7 RECONDITION /_7 DESTRUCTION _f <br /> PUMP INSTALLATION /' PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 — <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 Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ _ .11 Other Other Information <br /> Geophysical I Surface Seal Installed B <br /> PUMP INSTALLATION: (Contractor kA, <br /> [Type of Pump 'ken-- H.P. <br /> PUMP REPLACEMENT: L/_7 State Work Done <br /> PUMP .REPAIR: L/7 State Work Done <br /> EB TRUCTION OF WELL: ' Well Diameter �- Approximate Depth <br /> Describe Material and Procedure <br /> I <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 of completion 1 <br /> p m'S' work on a new well, i will furnish the San Joaquin: Loca1'HeAlth District s <br /> WELL DRILLERS REPORT of- the well and notify them before <br /> putting..the. well in use.. The above <br /> information is true tothe best of my .knowledge and belief. I WILL CALL FOR'A'GROUT INSPECTION <br /> i PRIOR TO GROUTING AND Ai FINAL INSPECTION. <br /> j SIGNED I <br /> TITLE c <br /> I 11: (DRAW PLOT PLAN ON REVERSE SIDE <br /> WIVDEPARTMENT USE ONLY <br /> 1 PHASE I <br /> j APPLICATION ACCEPT AIA VEl DATE 7 <br /> ADDITIONAL COMMENTS: - -- T---- <br /> PHASE II GROUT. INSPECTION P . S FIN NSPECT ON <br /> I INSPECTION BY 1�' DATE INSPECTION DATE �� <br /> �! E H 1426 Rev. 1-74 <br /> -0 1-74 2M <br />