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V SAN JOAQUIN LOCAL. HEALTH DISTRICT /Va �� l;-� 2 � <br /> xCn„ <br /> FOR-OFFICE USE: � 1601 E. Hai-zr torsi Ave. , ,Stockton, Calif.' C <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.177 lao) <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued aT <br /> �n (Complete In Triplicate) <br /> Applicationri`s 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. F <br /> JOB ADDRESS/LOCATION : CENSUS TRACT <br /> Owner's Name <br /> f Phone <br /> i <br /> Address <br /> city , Q. <br /> Contractor's Name Awe, �l ,��� �L,,,,� License !tZfS/ Phone!ZyP-$/S 2 <br /> TYPE OF WORK (Check) : _ DEEPEN /�/ RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,` ,, SEWER LINES ,$ °° PIT PRIVY <br /> SEWAGE DISPO AL YIELD CE S5 POOL/SEEPAGE PIT -- OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WELL " — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 'Industrial, _ _X 'Cable Tool t Dia, of Well Excavation /Z 1 _r <br /> Domestic/private Drilled Dia, of Well Casing N <br /> Domestic/public Driven Gauge of Casing <br /> ' s11 <br /> Irrigation Gravel Pack Depth of Grout Seale <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other . Other Information1r <br /> '� ,C <br /> "' <br /> Geophysical siirr..a Cnnl T +� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> y£ _. - � <br /> PUMP 7REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe Material and Procedure" . <br /> F. <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local HealthIDistrict <br /> and °the State of California pertaining to-or regulating well '-construction. WitUHea <br /> IFT EN DAYS <br /> after completion of my work on a new well, 'I will furnish the San Joaquin ocalt District a <br /> WELL DRILLERS REPORT of the wall and not`� y`them before putting the:well n seabove <br /> information is true to the st £ mrowledge and 1 f. I WILL C L 4(-GROUT- INSPECTION <br /> PRIOR TO U NG A FIN PE , A <br /> SIGNED TLE <br /> RAW PLOT PLAN VN RE ERS SI <br /> t" <br /> FOR DEPART NT USE <br /> PHASE I <br /> APPLICATION _ACCEPTED BY.._. ! 4 --_DATE <br />; ADDITIONAL COMMENTS: <br /> PHASE II' GROUT- INSPECTION FHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPEC N BY DATE <br /> ., _ <br /> 2M <br /> E H 1426 Rev: 1-74 <br /> t�77 : - <br />