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�r Vv SAN JOA UIN LOCAL HEALTH DISTRICT -- ---- <br /> FOFUPFICE USE: .1601 E. Hazelton -Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-g374d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issueda <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 ;wade 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 a CENSUS TRACT <br /> Owner Q s Name - � FARM__ //VC, Phone 6-, ,2-q Y Fr`7 <br /> Address `' city <br /> Contractors Name Ile 14C k— „ ZZI�_.` _.. License #=7,? Phone " <br /> TYPE 0 WF ORK Check NEW WELL DEEPEN r RECONDITION" ' <br /> _ (Check): � V y .�/� ... /_� DESTRUCTION /� <br /> _ _ _ <br /> PUMP INST CATION / / ` PUMP REPAIR / / PUMP REPLACEMENT /7 � <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOTjT—FIELD CESSPOOL/SEEPAGE PIT OTHER ,\ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELI: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of-Well Excavation /° ?A' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing sC�. <br /> Irrigation Gravel Packs , .Depth of Grout Seal- <br /> Cathodic ProtectionRotary-' Type of Grout AV <br /> Disposal �- Other Other Information` I <br /> Geophysical Surface Seal Installed By: Ve,4� <br /> PUMP INSTALLATION: Contractor _ +_ <br /> Type of pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /-7 Sts te.Work_Done.._.- <br /> 2ESTRUCTION OF WELL: Well Diameter Approxiiziate 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 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 /> PRIOR TOG TING AND AdINAL INSPECTION. <br /> SIGNED TITLE .26d, <br /> (DRAW -PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY c, `7 f�F + DATE S- 11- 7 � <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT SPECTION PHASE III FI INSPECTION <br /> INSPECTION BY DATE —*---77 INSPECTION BY DATE-7— <br /> H <br /> ATE7H 1426 . Rev. 1-74 1-74 2M <br />