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SAN JOAQUIN LOCAL-HEALTH DISTRICT p� <br /> F(S OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. / y <br /> Telephone : (209) 466-6781 - r/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-11�d <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued CfS'7� <br /> (Complete In Triplicate) <br /> Application is hereby madejto 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 Joaqui <br /> County Ordinance No. - 1862 and the Rules and Regulatioris of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��} / CENSUS TRACT <br /> Owner's Name Lt k00 All At ` Phonerp�y �� <br /> Address L, "� 4 City <br /> AA A <br /> Contractor's NamebiLicense # 31ZpQUy Phone 3( }_ 3, <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION /—/ DESTRUCTION /_7 <br /> PUMPIINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> ' 0 then <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Zoo PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPEkTY 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 j,;)� - <br /> X_ 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> T <br /> t PUMP .REPAIR: / / State Work Done <br /> DES•TRUCTION 'OF WELL: Well IDiameter Approximate Depth <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 a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthewell 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 I SP$CTION. <br /> SIGNED TITLE -�� <br /> 11 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ff�� <br /> APPLICATION ACCEPTED BY DATE -2, -✓7, <br /> ADDITIONAL COMMENTS: b <br /> PHASE II GROUT :INSPECTION PHASE III/FINAL INSPECTION <br /> } INSPECTION BY !DATE INSPECTION BY I� DATE- /7„/�-•]"7 <br /> E H 1426 Rev. - I-74 0!77 _ 2M <br />