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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0:W!,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Diattict 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 NW Corner Linne Road & Tracy Blvd. CENSUS TRACT .f <br /> Owner's Name R. C: Xennedy Phone 209/835-7+39 <br /> Address 27867., Traey Blvd. City Tracy <br /> Contractor's Name Western Well Drilling Ltd. . <br /> Co., License # M182 Phone 29574332 <br /> I <br /> TYPE OF-WORK (Check):.- NEW WELL7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION f <br /> PUMPrI ST LATI6N Cl- PUMP REPAIR /� PUMP REPLACEMENT /7 ; <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 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 s Cable Tool Dia. of Well Excavation <br /> v .. <br /> , .Domestic/private Drilled Dia. of Well Casing <br /> 'Dome'stic/public '' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' . <br /> Disposal ' Other Other Information <br /> Geophysical, r Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: / / State Work Lne <br /> PLW !REPAIR: 97 State Work Done Repair bowls <br /> QEStlRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws land 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 t <br /> information is true to the-best-of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTI G D A FINAL INSPECT 0 . <br /> SIGNED TITLE Vice President 12/1.676 <br /> W LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTME!Tr USE ONLY ; <br /> PHASE I - .—.. <br /> APPLICATION ACCEPTEDBY DATE '"'� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II AL INSPECTION <br /> INSPECTION BY DATE (INSPECTION BY DATE Gam-- 7 <br /> S 1426 Rev. 1-74- _ J 1-74 2M <br />