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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-ALF9,41 <br /> ll <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (Complete In Triplicate) <br /> Application is 1Nereb 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/LOCAT Og 2 (a 16 AllsL4,4 ZL9d CENSUS TRACT <br /> Owner's NamePhone ,3fj- �tj/rx <br /> Address _ 21 2 City < x`144 <br /> Contractor's Name 2 �' License Phone <br /> TYPE OF WORK (Check) : NEW WELL ;. DEEPEN,'/—/ RECONDITION /_7 DESTRUCTION. /-7 <br /> - PUMP INSTALLATION / / PUMP REPAIR% /_.,PUMP REPLACEMENT /? ' <br /> Other /' <br /> DISTANCE TO NEAREST: SEPTIC TANK!aQ ' ,.SEWER LINES. PIT PRIVY <br />! SEWAGE DISPOSAL'JFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC-DOMESTIC WELL <br /> INTENDED USE - i TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Industrial� � Cable Tool . Dia. of Well Excavation, <br /> Domestic/private Drilled E 'Dia. of Well Casing <br /> Domestic/public Driven 'Gauge of Casing <br /> Irrigation Gravel Pack 4Depth of Grout Seal__ <br /> Cathodic Protection Rotary �r-Type of'Grout --ii -, <br /> Disposal Other ICO,ther Information <br /> Geophysical . -Surface Seal Installed By:,.<,j<�a,, f :FCcsroivj <br /> fn�� r <br /> PUMP INSTALLATION: Contractor �,�tP 3'Z� �� t <br /> Type of Pump S� - H.P. 5 <br /> PU.ME' REPLACEMENT: / / State Work Done - <br /> r" <br /> /.� _Wo <br /> PUMP `REPAIRt" _ State` rk Done ;.'i ""• , :" �x : "'"`" � �' "' <br /> DESTRUCTION OF WELL: - Well Diameter .t - - - —Approximate Depth <br /> Describe Material and' Procedure / <br /> .* = IX- <br /> I hereby agree to comply faith '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 /> aftr 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 -o myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOE�:*OUTINg, <br /> jANDA 1,5VEGTION. <br /> SI=GNED TITLE Al <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY::-. DATE �J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PECTION I P S II/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> k _ 1177 <br /> E H 1426 Rev. 1-74 -.--- . - <br />