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E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. 65 <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-f7-17y <br /> 1, <br /> I THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date .IssuedDEC 22 1977 <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 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 351-S,-S, CENSUS TRACT <br /> Owner's Name fit'c V 199e Phone <br /> t <br /> Address �s r 'T7'<✓ <br /> / Pc�r o C i y . <br /> Contractor's Name ,W1crezz,twl- /vcst fagg-7y License Phone 4av jr <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / /,, DESTRUCTION ./_7 <br /> AL _ <br />€ PUMP INSTLATION REPAIR / / PUMP REPLACEMENT <br /> Other — _ <br /> DISTANCE TO NEAREST: SEPTIC TANK /ZJ SEWER LINES 60 PIT PRIVY,. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT .6THER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> E 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 (,ti <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> E <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor fav Pru..a9 i_,( <br /> I� Type of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done _ <br /> DES-TRTJCTION OF WELL: . Well Diameter Approximate Depth r' <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 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> iPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> f SIGNED TITLE ,� .�1e,_ <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY \�VLCA C51- DATE Z.Z <br /> ADDITIONAL COMMENTS: _ _.__ •. w <br /> PHASE II GROUT INSPECTION . ;°3 .�, PHASE III/FINAL .INSPECTION- _ .._... <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 <br />+ <br /> x'!77 <br /> E H 1426 Rpv. , l-74 <br />