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F SAN JOAQUIN-LOCAL HEALTH DISTRICT s <br /> FOL OFFICE `USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 S74ZId <br /> F <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 Joaquin <br /> County Ordinance, No.. 1862 and the Rules and Regulations. of the Sa Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I bJAjr :- CENSUS TRACT <br /> Owne'r's Name - JOE 7 TO$T'A 'GUY CHAMBERLIN CONT. Phone ` <br /> M <br /> Address 21267xCORRAL HOLLOW ROAD cityy <br /> Contractor's Name i INZ,.License # 29n813 Phone 545-1185 <br /> 4 <br /> L <br /> .�r.H+�.�.;..r.'-n.�.:`ter .- _ - _ -- _ —:.l.i.�cw..r----ate.—• <br /> rTYPE OF WORK _(Check) : NEW WELL /g/ DEEPEN /_/ RECONDITION /% DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-J <br /> ,at Other / / — <br /> DI'STANCE' 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 " p� <br /> Domestic/private, ,. Drilled Dia. of Well Casing 8t,. <br /> i Domestic/public Driven Gauge of Casing 160V \ <br /> Irrigation - �a Gravel Pack Depth of Grout Seal 501 Q <br /> Cathodic.Protection Rotary Type of Grout BENTONITE <br /> Disposal Other Other Information SLEB BX OWNER <br /> Geophysical Surface Seal Installed By: <br /> DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. / / State ,Work Done <br /> /�/ State�Workone' °. --• " "`.'_ <br /> -PUMPT"REPAIR: <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> �\� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health-lDistrict <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a nein well, I will furnish the San Joaquin Local Health District a ' <br /> WELL-DRILLERS REPORT "of the well and, notify them,before putting the "rae'll in use. The above <br /> information is rge .to the be of 'my knowledge and belief. I WILL' CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU �F NAL NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY ' DATE . <br /> ADDITIONAL COMMENTS: <br /> PHASE, I ' GROUT INS159CTIOWPHUE III4FINAL INSPE T ON <br /> INSPECTION BY DATE .<�_ 2 INSPECTION BY DATE .f <br /> E H 1426 Rev. 1-74 177' 2M <br />