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UTING SOH. �07t 7 :30 1'ri. 9%16/77 <br /> _ JOAQUIN LOCAL HEALTH DISTRICT`,/ <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nol77 le <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 District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION = 6' ^cst Jack 'iore 1.6y & J6 !,Ile South harrey TanGENSUS TRACT <br /> Owner's Name Her Hardin PhoneS f- 4 <br /> Address 'i 4 '�=es; Te?-i:�, �cocktUrL, 0,11` f- c;520City JIsve <br /> Contractor's Name ruri,i­lr_ce ri 1 e_s,r,6.s x t,4.,?lnaen,0 1 _ f. License # 20107 Phone ;i'-la-0 <br /> TYPE OF WORK (Check) : NEW WELL /�X7 EEPEN /_7 RECONDITION OESTRUCTION �] <br /> --3ifiSTALLATION / / PUMP REPAIR _/ / PUMP 7REPLA>tMDff� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 9001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 900' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ x Cable Tool Dia, of Well Excavation " <br /> '�- Domestic/private Drilled Dia. of Well Casing c" <br /> Domestic/public Driven Gauge of Casing T2 <br /> Irrigation Gravel Pack Depth of Grout Seal 55' <br /> Cathodic Protection Rotary Type of Grout set er;ent <br /> Disposal Other Other Information Jacket conductor pipe - 12" <br /> Geophysical Surface Seal Installed By: <br /> X Stock <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> P/ _ �- State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 10 Approximate Depth <br /> Describe Material and Procedure Fbackfill sci7 to `u' - Genent to surface <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 TO GROUTINGAAWA FINAL INSPECTION. <br /> SIGNED '� jj�?/J TITLE t'ar�ner <br /> -r (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO TMENT UIF4 ONLY <br /> PHASE I % �y <br /> �2 <br /> APPLICATION ACCEPTED BYE C -0� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />