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I/ (� SAN JOAQUIN LOCAL HEALTH DISTRICT (/ <br /> FOS+ OFFICE E: p 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> ,Z APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISIiPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -77 <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 herein1described. 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 /> i <br /> JOB ADDRESS/LOCATION 2 y 17.2— �, d�',q h c� �, �c �Q1i ,� kENSUs TRACT <br /> Owner's -Name dZIA 0,0 LV Phon <br /> Address O rp 1? 01 (0 Aze -- - City s C �4 /D /;z <br /> 4 <br /> Contractor's Name CA r r el i License # 7 Phone.S 2 - <br /> TYPE OF WORK (Check): NEW WELLe/ / DEEP N / / r .RECOND�ION�e/ /x-:DESTRUCTION /-7- -PC1MP=iNSTAI-1ATi0N_ —PUMP,-REPAIR /--/' PUMP-REPUACEMPNT -'-/-7-- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK f S Q_ SEWER LINES/,5-a- PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD ./-rd ^; CESSPOOL/SEEPAGE PIT OTHER ) <br /> PROPERTY [LINE -- PRIVATE*DOMESTIC,WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia 0kof Well Excavation, <br /> K Domestic/private I Drilled �~ Dia: of Well Casing - <br /> Domestic/public Driven Gauge of Casin _ <br /> A Irrigation '` ,, Gravel Pack ! Depth of Grout Sealmm <br /> ,Cathodic Protection .` Rotary Type7of Grout <br /> `"Disposal VOther Other Information <br />____�jGeophysical ; ' • Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of rPump <br /> PUMP.REPLACEMENT: / / State Work Done <br /> PUMP_REPAIR: / / State Work D�ne—,-•i <br /> DESTRUCTION OF WEILc` We-11 Diameter' Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to slmp-ly with all Laws and regulations of the San Joaquin Local Health District <br /> and the State of Californiz pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work onta 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 GRO TING AND A FINAL INSPECTION. <br /> SIGNED . TITLE 6 J j//7 -f j ' - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> Q FOR DEPARTMENT USE ONLY <br /> PHASE I /� / <br /> APPLICATION ACCEPTED BY GCI! DATE 6 7 <br /> ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION P S�tfa/FINAI, INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 _� <br />