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SAN JOAQVN LG,CAL. HEALTH DISNRICT <br /> FOF, OFF r USE: k 4 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -J,�/l/� <br /> 77-�µ4l0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) ' <br /> 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z B CENSUS TRACT <br /> Owner's Name `e/ 4 5 Phone , '� 3� - a'�©. <br /> Address j �` / !� 1//� L f City &J lae- <br /> Contractor's Name 0d55 (A Q.V I A-N c� ���i License # Phone <br /> TYPE OF YORK (Check) : NEW WELL/✓/ DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /L/� PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK0 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 r_/V <br /> Domestic/public ' !/Driven Gauge of Casing N <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 9 �AIAl Td 7 <br /> Disposal Other Other Information <br /> Surface Seal Installed By:R,4 T <br /> PUMP INSTALLATION: ContractorZIC / <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL.: a Well Diameter b Approximate Depth <br /> Describe Material and--'Procedure <br /> SD - �v <br /> I hereby agree to comply with all laws and regulations of the San Joaquin LocalHealth Mistrict <br /> and the State of California pertaining to or regulating well •construction. 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDrr` TITLE Al t`'� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1-26-78 <br /> PHASE I ,/p <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -7 7 INSPECTION BY DATE <br /> 11-10'78 0W7r wi�/it9/l�oc�y Sc a/ �� <br /> G - , <br /> 1177 <br /> E H 1426 Rev. 1-74 <br />