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- 1 <br />- r SAN JOAQUIN LOCAL'HRALTH DISTRICT <br /> FOP, FFICE USE: li ,601 E. Hazelton,Ave. , Stockton, Calif. i <br /> Telephone: (209) 466 6.781 1 <br /> APPLICATION FOR WELL COI35TRUCTION OR PUMP PERMIT Permit No. <br /> THISyPERMIT EXPIRES .1-Y'EAW FROM,DATE ISSUED Date Issued 3 ??� 4 <br /> _77-77-7 <br /> ;.(Complete Iii.Triplicate) <br /> nstruct <br /> App <br /> lication is hereby made to the San Joaquin LocallHealth District furca Permiteto co San Joaquin ; <br /> and/or install the work herein described.. This application ismamP <br /> County Ordinance No. •1862 and the'.Rules and Regulations of the San Joaquin Local Health District. <br /> pfd/�l f/rrv0z i2o IleusF 7W-57,06 CENSUS TRACT ; <br /> JOB ADDRESS/LOCATION ,�.� v s F Loi" o <br /> ;• m �77� <br /> Phone �l�" _ <br /> Owner°a Name ; i a HW2 ` TTG <br /> city Za 6/3 <br /> Address z . <br /> License # Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) :.--NEW._WELL1/_7_DEEPEN�1_7-TT"RECONDITION-/?,-DESTRUCTION -T <br /> FUMP�IN5TALLATION I I PUMP, REPAIR /7 ' .PUMP REPLACEMENT7V <br /> - <br /> l Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> PROPERTY LINE -_PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ tl! CONSTRUCTION SPECIFICATIONS T <br /> industrial Cable Tool . I`Dia. of Well Excavation <br /> Domestic/private - Drilled `.'Dia, of Well Casing <br /> Domestic%public =Dirive�i� ' Gauge of Casing <br /> Irrigation •� �,�. Gravel�Pack Depth of Grout Seal <br /> { t Cathodic`Protectri-on Rotary Type of Grout <br /> Disposal Other , Other Information <br /> Geophysical ^ Su rface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> A.P. <br /> ! Type of 'Pump <br /> i / / State Work Dane x,/L ! f ,4e <br /> f PUMP REPLACEMENT: YS 7"Ph! <br /> i PUMP '-REPAIR: R State Work. Done <br /> ! - APpr-oximate,_Depth ^-- <br /> ES TRUCTION-OF WELL-: Well Diameter <br /> Describe Material and Procedure <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 8 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in.use.. The above <br /> d information is true to the-beet of my knowledge and •belief. I WILL CALL FOR A-GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECrI0.V San JoaquiH rump o. <br /> ;i-bivlsEoe ofSTin sulphur Co. <br /> SIGNED t' <br /> . . �' (DRAW PLOT PLAN ONS §EK n <br /> EPARTMENT ni <br /> PHASE I t � DATE ?moi <br /> APPLICATION ACCEPTED- BY r�. 7 i Ar c <br /> ADDITIONAL CAMMENTS:. '~di'll PHASE T I F NAL INSPECTIO <br /> PHASE I ROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION Wf DATE <br /> -7 4 2M <br /> E H 1426 Rev. 1-74 <br />