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SAN JOAQUIN LOCAL HEALTH DISTRICT a O✓ Cos, <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ✓ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' 7?- 77 l� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-�/77 <br /> (Complete In Triplicate) <br /> Lplication is hereby made t0 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 Joaqui <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> r21<le <br /> OB ADDRESS/LOCATION �1 I� �!/PSTO ( yy� �� CENSUS TRACT Of/--030.-0, <br /> er's Name <br /> �j/ o hock" C�/N Phone <br /> Address /6 02 �✓ evc� IIJ�m o�. �� F-5 X07 -city. <br /> contractor's Name License #, OeP7: Ss Phone A7 <br /> 1- <br /> �YPE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION / /' ^DESTRUCTION /7 <br /> PUMP INSTALLATION /q PUMP REPAIR/—/-PUMP REPLACEMENT /7 <br /> Other / / At <br /> �ISTANCE TO NEAREST: SEPTIC TANKp SEWER LINES PIT`PRIVY . 1 <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT t OTHER L <br /> PROPERTY LINE&PRIVATE DOMESTIC WELL X' PUBLIC DOMESTIC WELL Z <br /> INTENDED USE TYPE OF WELL CCNSTRUCTION�,SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation 'fie lk <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing 19 V3 <br /> Irrigation . Gravel Pack\� ` Depth of Grout Seal V) <br /> Cathodic Protection 17- Rotary Type of Grout -jQ" Wr_ b-ceQ. _'4-- <br /> L Disposal ! Other Other Information <br /> --Geophysical Surface Seal Installed By: cxac,G <br /> UMP INSTALLATION: Contractor <br /> Type o Pump lei �i^e. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> — t <br /> UMP .REPAIR:. <br /> / 1-State WorkDoneLL <br /> i <br /> ES•TRUCTION OF WELL: Well Diameter Approximate, Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my on a new well, I will furnish the San Joaquin Local�Health District a <br /> ,ELL DRILLERS REPORT f the well and notify them before putting the well in use, The above <br /> nformation is tto th st of my knowledge and belief. I WILL CALL FOR A,GROUT INSPECTION <br /> RIOR TO GROUT FINALINSPS&IOn. <br /> )IGNED TITLE - <br /> i (DRAW-POT PLAN 'ON RE EESE SID - <br /> .RASE I FOR DEPARTMENT USE ONLY <br /> TPLICATION ACCEPTED BY ! !22--r:77DATE /-,3/- 22 <br /> IDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I ,FINAL INSPECTION <br /> INSPECTION BY (/e(i��� DATE -y- ?7 6 INSPECTION BY DATE A- '7 t7 <br /> ' <br /> E H. 1426 Rev. 1-74 3/76 2M <br />