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SAN JOAQUIN LOCAL HEALTH DISTRICT ,11 <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ! <br /> . Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-17 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date IssuedC 28 1971 <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 Rues and Regul tions of th San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION M. � ��rr r I - CENSUS TRACT <br /> i c v' / <br /> Owner's Name �i w ! clr� A- Phone ����� i <br /> Address City � � •°y <br /> Contractor's Name// v rT r.47 A/ Ujyr f d, c License #,,107AK/ Phone <br /> TYPE OF WORK (Check) ; NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /- _ <br /> PUMP -INST.ALLATION /L PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK �-f SEWER LINES/C�,,-- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINHYP PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> f 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 /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �� .e �� � Ve Cc, <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> r <br /> DESTRUCTION OF WELL: Well Diameter 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 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 D A FINAL INSPECTION. <br /> SIGNED <br /> . •• .. ! ._•...__�r._ TITLET <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 II PKU,Y INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ]--�;�,7 <br /> E H 1426 Rev. - 1-74 <br /> _ 2M <br />