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SA JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> „ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUh?.PERMIT. Permit No. Z7- <br /> THIS <br /> 7THIS PERMIT EXPIRES 1 YEAR FROM-"DATE ISSUED----. Date Issued <br /> Ql( S' A-t"D leo 1`^ C u y (Complete In Triplicate) 177— 0.50'—©,3 <br /> Application is hereby made to the San Joaquin Local Health District j-or 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'�!d OW �� �, PD &O `Y2 H, CENSUS TRACT <br /> Owner's Name �,L Y L vo A) Phone f2-d; Q <br /> Address 0 J/ WCity <br /> Contractor's Name AY007 License # Phone G L <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INST ATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Q <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 5V 71�1 <br /> Cathodic Protection Rotary Type of Grout f <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ E <br /> - _ <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done p <br /> PUMP .REPAIR: / / State. Work bone <br /> DESTRUCTION OF WELL: Well Diameter L -•-r Approximate Depth <br /> Describe Material and Procedure <br /> — <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 completion of my work on a new well, I will furnish the San Joaquin Local Health Distri ct' 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY,\ft4M DATE <br /> ADDITIONAL COMMENTS: <br /> PHA E II G OUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 5477 INSPECTION BY DATE <br /> E H 1426 Cv. 1-74 t`/o + 1177 _ 2M [9 <br />