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C Ib " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE U E: 160I B. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-Na P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued )-/8'-7 <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 _S // fly!///-�NLK/TI'✓f+�� mar�B CENSUS TRACT <br /> Owner's Name Phone <br /> Address �(J r6 0 74 7 City V yyii�f �. <br /> License 0 /L3711'Thone , t,-74 X. <br /> Contractor's Name4� ,p1�sj� � r.�- �.(�, —• <br /> • t <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN RECONDITION /-T DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ ;P PUMP REPLACEMENT /7 <br /> — — i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 'S y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Do6es.t public Driven Gauge of Casing <br /> Irigaot� Gravel Pack Depth of Grout Seal <br /> T Cathodic Protection Rotary Type of Grout <br /> =Disposa� Other Other information <br /> Geophysical Surface Seal' Installed By: <br /> PUMP INSTALLATION: Contractor �� a <br /> 4 Type of Pump / l✓� i H.P. G-V <br /> PUMP REPLACEM96; / / • State Work Done 1 <br /> PUMP .REPAIR: lxl State Work Done` et�C / R. ✓V:r Aus���i /bum <br /> DESTRUCTION, OF WELL:'- Well Diameter f Approximate Depth tr Describe Material and Procedure-I hereby agree to comply with .all laws and regulations of the San Joaqui cel Health District <br /> and the State of California pertaining to or regulating_well'construction. : ti FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin, Local lth District 4 <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true to thebestm - owledg and belief. I WILL CALL,FOR A GROUT INSPECTION <br /> PRIOR TING AND A I SPECT � <br /> ,SIGF�t TITLE <br /> . D PLANE$SE SIDE , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,h <br /> APPLICATION ACCEPTED BY DA <br /> ADDITIONALEC COMMENTS:. - , <br /> • PHASE I1 GROUT INSPECTION -i,.�:, - III/ INSPECTION <br /> TE I <br /> INSPECTION BY DATE INS <br /> ". 3/76.. 2M.� <br /> .E H 1426 Rev.- 1-74 _ - - _v _ ._.. - - _.�;—_�f,• `° <br />