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!o e re SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .FOR OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7.i13r-Y, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (9-A-77 <br /> (Complete In Triplicate) <br /> applications hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquin <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San` Joaquin Local Health District. <br /> 'OB ADDRESS/LOCATION YJ2 % /j yf f�y_ T�� �I, ;' o/�� s -CENSUS TRACT <br /> timer's Name J91 a Phone <br /> - <br /> .ddressv o1 <br /> � l'G^� _ Cityi�- <br /> :ontractor's Name )� % X57, , . �C/ License # Phone _r <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEPEN / J RECONDITION-/—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /Lf/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> iISTANCE TO NEAREST: SEPTIC TANK 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/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 Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor '_ <br /> Type of Pum ` - F L / ^—� <br /> YP P Tc. v 41 1;-e H.P. -7L� <br /> 'UMP REPLACEMENT: / / State Work Done <br /> SUMP rB&MA3-R: /_Sd State Work Done _Z7jij lw =t �J�,_ •� l / \ <br /> ESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> if ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> _nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROITING AND A FINAL INSPECTION. <br /> 'IGNEDTITLE <br /> (L 'IN ON RSAAW TLOPLANT SIDE) <br /> —�' FOR DEPARTMENT USE ONLY <br /> 'RASE I y� � <br /> APPLICATION ACCEPTED BY �p1 '0. DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> ^NSPECTION BY DATE INSPECTION BY DATE <br /> F H 1117(+ o.,.. 1_7i. 6/77 _ 2M <br />