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SAN JOAQUIN LOCAL HEALTH DISTRICT v <br /> FOh+OFFICE USE. 1601 E. Hazelton Ave. ,,- Stockton, Calif. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 7,700 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued 7 ZL—_2 <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 Cl t4$ '7-ARK .RA, &,Gr:1°TS %54ml,0 CENSUS TRACT <br /> Owner's Name 4-410 „�.1k ! " Phones <br /> Address City STdGf:T¢fL^ <br /> Contractor's Name License #200719 Phone C/ 8ff <br /> f TYPE OF WORK .(Check): NEW WELL -/ DEEPEN '/_ -RECONDITION /_7 DESTRUCTION f_7 \ , <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT_ I� � <br /> Other / / — — — <br /> DISTANCE TO NEAREST: SEPTIC TANK M! SEWER LINES PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE " +, ' :. TYPE'OF 'WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ ZQ <br /> Domestic/private Drilled Digi: of" Well Casing 611 <br /> Domestic/public Driven Gauge of Casing s <br /> Irrigation Gravel Pack ; '.Depth of Grout Seal _ _3 FT <br /> Cathodic Protection Rotary r..,,, 'A IType of Grout C,/26_7& : .. <br /> Disposal Other Other''lnformation <br /> —Geophysical Surface Seal .Installed By: _AAnACK Lail W <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - \ �. .. H.P. <br /> PUMP REPLACEMENT: L/ State Work Done " <br /> PUMP '.REPAIR: L7 State Work Done <br /> ,?ESTRUCTION OF WELL: Well Diameter Approximate, Depth. <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 oi- 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 :anis °belief.L 'I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU NG AN A FZNAL INSP ION. -- <br /> SIGNEDTITLE r <br /> J JL DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -as"-�� <br /> ADDITIONAL COMMENTS: <br /> PHASE It GROUT INSPECTION PHASE III FINAL INSPECTION <br /> i <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />