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vdv SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: . 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209,) 466-6781 <br /> PLICATION FOR WELL' CONSTRUICTION OR PUMP PERMIT Permit No. ] <br /> 77-J6 dp. <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .L_ 3__62-2 <br /> I <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/ti j CENSUS TRACT <br /> Owner's Name r j��' <br /> e-� Phone � f <br /> Address City <br /> r <br /> Contractor's Name }"tj�f(,� g � . , �S/� License Phone.��-_�o <br /> _ i <br /> TYPE OF WORK (Check) : NEW WELL ) DEEPEN/ / RECONDITION /_� DESTRUCTION /`7 4r� <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT / Gt <br /> c " <br /> 0 tti'er /f / <br /> DISTANCE TO NEAREST: SEPTIC TANK S 7- SEWER LINES "(! PIT PRIVY r- ' <br /> SEWAGE M ELD DISPOS CESSPOOL/SEEPAGE PITZ.Z4 J` OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELLI'�1'YUBLIC DOMESTI <br /> INTENDED USE TYPE OF WELL C WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool y Diat,"of Well Excavation _ z_ <br /> Domestic/private Drilled t Dia.­,of Well Casing <br /> Domestic/public Driven Gauge of Casings <br /> Irrigation i Gravel Pack j�Depth of Grout �Seal <br /> Cathodic Protection Rotary <br /> Type of Grout <br /> Disposal Other Other Information <br /> Geophysical -- * 4 . <br /> - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor *,t7�p'yf/j ? 5 �' <br /> Type of Pump - -,- H.P. <br />?UMP REPLACEMENT: / / State Work Done <br />'UMP -.REPAIR: <br /> _ / /,.State Work,Done_ <br /> k <br />'ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree tb-,:op 1Y +with a1l''17a_ws-and rdgulations of theSaiz jo, aquiri" coal-Health District <br /> r <br /> tnd the State of California pertaining to or regulating well "construction. Within FIFTEEN -DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District_ a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br />.nformation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED /jITLEel--5, <br /> �(DPLOT PLAN OW REVERSE SIDE) <br /> RASE I FOR DEPART LlENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: / <br /> PHASE II GROUT INSPEC ION PHASE III/FINAL INSPECTION <br /> NSPECTION BY _ DATE INSPECTION BY DATE <br /> / G�--•f/ <br /> E H 1426 Rev. 1-74 1/77 7M W, <br />