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SAN JOAQUTN LOCAL HE -- -• -- • v.,._ <br /> h ,�FFICE USE: 1601 E. Hazelton HEALTH DISTRICT <br /> Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU ppR1yzT <br /> Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE 77-/9-3 <br /> (Complete In TripliDate Issued -/S�7 <br /> Application is hereby made tcate) <br /> o the San Joaquin Local health Distr t for a <br /> permitand/or install the work herein described. This application is de in compliancetwithnSanuJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of an -Joaquin Local Health District <br /> 2 <br /> JOB ADDRESS/LOCATION Qp <br /> E Esus' TRACT <br /> Owner's Name c% -- <br /> ' <br /> Address Phone Sag - -774 <br /> ,3/417 E. f& City �SC4Lo N <br /> Contractor's Name EJ 4 /I <br /> C License ;Z16 'h Phone,52 <br /> TYPE OF WORK (Check): NEW WELL /W DEEPEN /`7 RECONDITION <br /> Other <br /> ALLATIQN / PUMP REPAIR '/� PUMPEREPLACEMEN _ <br /> Other %/ /? <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 3-� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESS OP QL/SEEPAGE PI <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLICJ+`OTHER <br /> INTENDED USE TYPE OF WELL C WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> _ Cable Tool Dia. of Well Excavation „ <br /> Domestic/private Drilled <br />_ _ Domestic/piib-1 C- < - --_ Driven Gau <br /> of Casi <br /> Irrigation _.__)S._ Gravel Pack Depth of GroutSeal <br /> Cathodic Pr_otect_ion _ X - Rotary Type of Grout <br />-„_Disposal �_ Other Other Information <br /> _Geophysical -----�- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION; E <br /> Cgntractor Ilow <br /> Type of Pump i 3 <br />?UNP REPLACEMENT:, State Work Done <br />'JMP 'REPAIR: y _ _ /? State Work-Done. <br /> LES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth \ <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />.nd the State of California pertaining to or regulating well ••construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and notify them before putting.the.-well. in.use.... The above <br /> nformation is true to .the of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />�IOR TO GROUTIN D A FI <br /> IGNED UAL INSPECTION. <br /> TITLE Sa� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> iASE I DEP T USE ONLY <br /> PP CIL ATION ACCEPT Y <br />)DITIONAL COMMENTS: L 1/1��T- DATE Z-1144,77 <br /> PHASE I GROUT INSPECTION S AL <br /> ISPECTION BY, DATE PHAIII INSPECT ONINSPEC TON BY <br /> �- DATE <br /> E H 1426 Rev. 1-74 `l8 ?7 7 L <br /> � •fa+. 1J a c. <br />