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�/1-7- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE• 1601. E. Hazelton Ave. , ,Stockton, Calif. <br /> % 3 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7?^ 3171t <br /> THIS PERMIT p <br /> EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �3-30- 77 <br /> (Complete In Triplicate) <br /> Application is tereby"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 District. + <br /> JOB ADDRESS/LOCATION S �' C?[ CENSUS TRACT <br /> Owner's'Name+ 1414 Al "I C' Phone r 11 _.Et , - <br /> Address U U l -S i_:::: City iC 1 <br /> Contractor's Name /i(/ gip, ppb, 'cense // '{�/�3Phone �- 37V <br /> 1� <br /> i <br />~TYPE OF WORK Check) : NEW WELL _ _ R <br /> ( /GI" DEEPEN / RECONDITION /� -REST-&UGTIOIV- /7 •• <br /> PUMP INSTALLATION /PUMP REPAIR '/ / PUMP'REPLACEMENT /� - �1 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'PITrTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL CONSTRICTION SPECIFICATIONS <br /> In strial. 1 Cable Tool Dia. of Well Excavation <br /> omestic/private 1 Drilled Dia. of Weil Casing, 1\ (, <br /> Domestic/public 1. Driven Gauge of Casing <br /> Irrigation 1Gravel Pack Depth of Grout Sea <br /> Cathodic Protection 1 teary Type of Grout <br /> Disposal I. Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor ( <br /> Type of Pump _.� H.P,' <br /> PUMP REPLACEMENT: / / State Work Done , <br /> / / State Work Done zxa_cL <br /> DESTRUCTION OF WELL: Wellrameter JApproximate Depth <br /> Describj] .,Mate al�and Procedure <br /> I here ee' 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..-Heaith ..District a <br /> WE14, DRILLERS REPORT of the well and notify 'them before putting the well in use. The above <br /> inf tion is true to e bof my knowledge and belief. I WILL CALL' FOR A GROUT INSPECTION <br /> PRIOR ROUTING tFI N E ON. <br /> SIGNED — TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOROLDEPARTMENT USE .ONLY <br /> SE I <br /> APP CCEPTED.BY ®---- DATE 3 Q <br /> ADDITIONAL COMMENTS: " <br /> PHASEGROUT NSPECT ON PHASE I/FIN INSPECTION <br /> INS'Pj�CTION BY ATE 44,_/_t77, % INSPECTION BY DATE r• j-- <br /> ,_ , E H 1y.. Rev. 1-74 / -�.� .. 1/I7 - 2M <br />