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!'fx SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT,,.. OFFLCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 -76'4{J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3 <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 District. <br /> JOB ADDRESS/LOCATION �' ! -�� � C ,. , `�l &US TRACT <br /> 6 <br /> I <br /> Owner's Name f.C.0 -P_a 4f � one 2,37722_2,-,s <br /> Address City <br /> Contractor's Name L . License # Phone <br /> i� <br /> TYPE OF WORK (Check) : NEW WELL /!il DEEPEN '/—/ RECONDITION / / DESTRUCTION <br /> " PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 # <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _&__ CESSPOOL/SEEPAGE PIT OTHER teaa-16 <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 f <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information - G <br /> Geophysical Surface Seal Installed By- <br /> PUMP <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. H.P. <br /> y 4 I <br /> PUMP REPLACEMENT: . / / CS�t�at6'Work Dane iZ <br /> s <br /> PUMP :REPAIR: �--- / Done 1 <br /> 67DESTRUCTION ELL: Well Diameter " } ' i , y! a Approximate Depth <br /> Desc ibe Materia, andyP- - cedur <br /> ,r <br /> I hereby agree to comply with al laws a regulations o the San Jo-94uin Loca H It Distr ct <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 tl;�.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 GR.OUTING AN NAL I PE TION. <br /> SIGNED (,G TITLEe <br /> (DYAW _PLOT PLAN ON RE SE SIDE) <br /> FOR DEY7ARTMENT USE ONLY <br /> PHASE I DATE (Y" <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS. <br /> P IOU INSPECTI N PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE //-/ ] <br /> � 1177 ZM <br />