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I / SA1�,WJAQUIN LOCAL HEALTH DISTRICT "�W <br /> OFFICE USE: (/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2F-/4 LeJ <br /> 76-/8sP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' . _S 7 <br /> (Complete In Triplicate) <br /> ication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i/or install the work herein described. This application is made in compliance with San Joaquin <br /> 1^ty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .ADDRESS/LOCATION CENSUS TRACT <br /> :'s Name ('/! ,r` / - �/ ,r h Phone .7C <br /> 3ress WOODS WELL DRILLING Cit <br /> 119M Simmerhorn Road Y <br /> Gal[,California 95632 <br /> actor's Name }/;; �/r �,✓�fij , ,//r q c; License # T C Phone <br /> OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /;l PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> INCE 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 t-�Cable Tool Dia. of Well Excavation <br /> i- " Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing dYh, <br /> Irrigation Gravel Pack Depth of Grout Seal >>( <br /> Cathodic Protection Rotary Type of Grout `/. ,r> <br /> Disposal Other Other Information <br /> .Geophysical Surface Seal Installed By: A <br /> ^ INSTALLATION: Contractor <br /> Type of ' <br /> YP Pump i, /-, H.P. %J'l" n <br /> T REPLACEMENT: / / State Work Done w <br /> REPAIR: / / State Work Done <br /> UCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F-eby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> he State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> tr zompletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> mation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> TO GROUTING AND A FINAL INSPECTION. <br /> NED �l/. ; r' / 7,-77>_ TITLE . '?' 7:-c <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> SE I <br /> II`CATION ACCEPTED BY �'%� DATE <br /> I ZONAL COMMENTS: / <br /> PHASE II GROUT INSPECTION ✓ PHASE III/F NAL INSPECTION <br /> PnCTION BY L, /,' DATE zL u7C INSPECTION BY /�. w. DATE ✓_/: �% <br /> E H 1426 Rev. 1-74 1-74 2M <br />