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SAN JOAQUIN LOCAL. HEALTH`DISTitICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77,x/# <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,-'/g_77 <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 San Joaquin Local Health �?istr�c`t. <br /> /#safe y Da ae eQ8 e f iP, Ca m/ i,Qd�'to r -e c`r,"'4'a ,(,y� /M= <br /> JOB ADDRESS/LOCATION J tekh&mew e At-F. 5��. Sn-LreSfl�%o Cr CENSUS TRACT <br /> ager 4c-M#* d e Fjt&y Cr. 4r &P V.nivs <br /> Owner's Name a2W.10ujy eo u" Akl4G 4vdel s' Phone <br /> Address /?Ur yrs !8!p City S1b cel <br /> Contractor's Name do/'e W.JircizNm" License # Phone <br /> TYPE OF WORK (Check) ; NEW WELL/ J DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / Test h0rtW#;Ar 6uu <br /> DISTANCE 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 /> Geophysi�-��s Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: 1 <br /> A/ <br /> / J State Work Done <br /> DESTRUCTION OF Well Diameter a`3 Approximate Depth ' cJ <br /> Descri. Materia 4nd ProcedureaJ <br /> II 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 <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE g t$le�r' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE JP <br /> /7Z�_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION j PHAS T I/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 1177 2M <br />