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SAN ICAQUIN LOCAL HEALTH!DISTRICT <br /> j FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 3J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `77-.3 , l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7- 77 <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 <br /> /rcJ�ry.L CENSUS TRACT <br /> Owner's Name ,a,u 2-q 1&rL0 4 M- yc,` <br /> Phone <br /> Address I a-A �T�l�.lE Lc G city 5aA-10jj f. <br /> Contractor's Name �,yrb �2►l��N �� License Phone 4634- P3 <br /> TYPE Of' WORK E° <br /> (Check)=; NEW WELL DEEPEN / / A <br /> ALRECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTLATION /g/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE rTO, NEAREST: SEPTIC TANK - SEWERLINES t PIT PRIVY <br /> � SEWAGE :DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - _OTHER <br /> =: <br /> 30 � PROPERTY LINE - PRIVATE DOMESTIC WELL �o PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECT-FICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled <br /> 'Damestiprivate "" --" ' " <br /> VDia:""of`Well CasngQ <br /> i ` "tDomesfic/puBlic + '"Driven"`"``"`"' Gauge of-Casing "'�' '-ry;� _' <br /> •r Irrigation j- Gravel Pack Depth of Grout Seal Y t`-: -E <br /> -• iC thodic Protection i X Rotary Type of Grout '"4'1._1' <br /> :Disposal j Other' Other- Information <br /> '%`!Geophysical Surface Seal Installed BY: ,1ine,rea _D1t1/ r <br /> 'T UMP_ INSTALLATION: Contractor ,�'�- <br /> Y k `3-;. Type of�Puinp S H. <br /> ri p <br /> PUMP REPLACEMENT; . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> �. <br /> DESTRUCTION OF WELL: Well Diameter _ _ - "--� Approximate Depth `*• <br /> Describe Material and Procedure . <br /> I hexeby gree to comply with all laws and regulations of the- San Joaquin Local Health District <br /> and1the'State of California pertaining to or regulating well-construction, Within FIFTEEN' DAYS <br /> after•- complet on�of'my c5ork onca...new well;.yI -wi TZ furnish 'the_ San ";7,aa uYiz�L�oc'al Hea=Zth 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-be'lf-ofkmy'.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ; <br /> PRIOR TO `GR U ING AND A FIN NSPECTION.' -» <br /> SIGNED TITLE <br /> I}RAW PL T' PLAN 'ON REVERSE SIDE) `' ". �•,s :l „ <br /> FOR WARTMENT USE ONLY <br /> PHASE a <br /> I <br /> APPLICATION ACCEPTEDEj <br /> DATE <br /> ADDITIONAL COMMENTS: ! z� <br /> PHASE _ I GROUT INSPECTION PHASIII IN INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ... 7 - A5A 3/76 2M 0 <br />