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SAN JOAQUIN LOCAL'HEALTH-DISTRICT F <br /> 1b01 E. Hazelton Ave. , Stockton, Calif. 77Y 3S/p } <br /> FOR OFFI_ Cis 466-6781 '�' <br /> Telephone: (209) <br /> APPLICATION FOR WELL CONSTRUCTION OR P" PERMIT Permit No. <br /> jDate Issued -7- 77 <br /> THIS1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete In Triplicate) <br /> I Health District <br /> rto construct <br /> P <br /> A plication is hereb made tol. the San Joaquin Localication is made inco pliancewith San Joaquin <br /> and/or install the work herein described. This app <br /> County Ordinance No. 1.$62 and. the Rules and Regulations of the San Joaquin Local Health District. <br /> !� CENSUS <br /> JOB ADDRESS/LOCATION v �� ���"'^ <br /> r 7 20 Phone <br /> Owner's Name <br /> /�"� ; l�0 I 6` 6-; 'City 9,4C•A z-C, / <br /> Address -°' <br /> f - I/ , <br /> License #_foo L Phone <br /> Contractor's Name <br /> x° T <br /> ; <br /> RECONDITION DESTRUCTION <br /> TYPE OF WORK (Check) : NEV1WELL CDEEPEN �IT <br /> 1_7 <br /> #INSTLATION PUMP REPAIR / Pip REPLACEMENT <br /> r <br /> SEWER.-LINES PIT PRIVY' <br /> DISTANCE TO NEAREST: SEPTICS TANK ` i°"tCESS oP LISEEPAGE PIT OTHER <br /> SEWAGE,DISPOSAL FIELD <br /> PROPERTY LINE - PRIVATE'DOMESTI.0 WEL1.790L PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> rr <br /> V__:�___INTENDED USE ""'Ib a. of Well Excavation-i-! l <br /> Industrial ; ;Cable Tool ; <br /> r , Dia. of Well Casing,-, <br /> Domestic%private 4 �� f Drilled -_.�,.. w <br /> -,�bNV <br /> �'" Gauge of Casing � <br /> Dometttt c/public � <br /> t Gravel' Pack Depth- of Grout Seal <br /> X Irrigation ar Type of Grout <br /> Cathodic Protection I:, 3_ Roy Other Information <br /> P <br /> Other-1—- c 4 T i W <br /> Disposal ---� . , .ti .f a Surface Seal Installed B r) <br /> `--. Geophysical' <br /> PUMP INSTALLATION: ContTAV <br /> ractor -d� 7 H.P. <br /> Type of Pump . <br /> 1 PUMP REPLACEMENT: %/ State Work Done <br /> PUMP .REPAIR: / / � State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well.Diameter <br /> Describe Material and Procedure <br /> cal <br /> I hereby agree to comply with all laws and regulations °welleconstrucion- �WithinaFIFTEENtpAYS <br /> ell, <br /> and the State of California pertaining to oI regulating <br /> will. furnish Local <br /> ish the San Joaquin Health District a <br /> after completion of my work on a new w <br /> WELL DRILLERS REPORT of the.well and noknowled em ndfore putting the well in belief. I WILL CALL FORuAeGROUTeabove <br /> INSPECTION <br /> information is true to the;best of my g <br /> PRIOR TO GRO TING AND A FI INSPECTION. TITLE 44.0Al <br /> SIGNED �'� <br /> DRAW. P , T' PLAN ON RE FRSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p S I/FI INSPECTIO <br /> PHASE II G OUT INSPECTION INSPECTION BY DATE 1i' <br /> INSPECTION BY D"ATE <br /> 3/76 2M <br /> Rav_ 1-74 __ <br />