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y SAN JOAQUIN LOCAL: HEALTH DISTRICT <br /> FOP -OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone : (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS;. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1­.zY-77 <br /> ii. (Complete In Triplicate) <br /> Application is- Aereby made to 11 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 - he Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ � Q �d ��� ���� -- CENSUS TRACT <br /> Owners Name fJ e k- Phone <br /> Address <br /> JC —/- city.. <br /> Contractor's Name zp License # Phone <br /> --....-- <br /> a <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other f/i / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSA,LYIELD `y-6671 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINF.4) PRIVATE DOMESTIC WELL _Z_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF:WELL CONSTRUCTION SPECIFICATIONS- <br /> 'Industrial <br /> PECIFICATIONS'Industrial Cable. Tool+ , Dia. of Well Excavatt&n _,,/o <br /> Domestic/private DriAlld : Dia: . o_f ,Well Casini'_ <br /> Domestic/public Driven .. G uge of Casing/ _ <br /> Irrigation Gravel Pack . , Depth of GrouewSeal <br /> Cathodic Protection Rotary '` Type of Grout ° >�., 24n_ j' <br /> Disposal Other rOther Info ma`tion <br /> Geophysical 1110Surface`Seal Installed By:"', ZF75 UJc77. <br /> PUMP INSTALLATION: Contractor" <br /> Type of Pump� er xis H.P. <br /> PUMP REPLACEMENT / / State Work Doone <br /> P0MP ,.REPAIR: / / State Work Done y ,„ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> _ <br /> Describe Material and Procedure <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 o' f-'my work on. a new well, I will furnish the San -Jba�quin Local Health District a <br /> WELL DRILLERS REPORT of t well and notify them before putting the well ini.use. The above' f <br /> information .is truethe best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT p ON, <br /> SIGNED -. TITLE <br /> (DRAW-,PLOT PLAN ON REVERSE SIDE) <br /> FOR DEL/TME USE ONLY <br /> PHASE I - _ <br /> APPLICATION ACCEPTED BY . '��- I .: DATA- 4� �?S <br /> ADDITIONAL COMMENTS: <br /> PHA UT INSPECTION P AL INSPECTION <br /> INSPECTION BY DATE/a%,/,- INSPECTION B DATE/ <br /> E" _2�/y,J� <br /> E H 1426`.1 ,;'.-Rp„_ i_7L <br />