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_ SAN JOAQUIN LeEAVIIIEALTH DISTRICT <br /> POE OFFICE USE: 1601 E. Hazelton Ave' , Stockton, Calif.w , ` <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- `717h-1 <br /> THIS#PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7/i -77 <br /> (Complete In Triplicate) <br /> 1pplication is hereby made to -the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work hereinldescribed. This:application is made in compliance with San Joaquin <br />;ounty Ordinance No. 1862 and :the Rules and Regulations of the San Joaquin Local health District. <br /> TOB ADDRESS/LOCATION Z3,154r 05 ^^41,.,X19 0_'e_ CENSUS TRACT <br />)wner's Name /pa YARit AS. + Phone <br /> addre ss J'4q //'r Ci ty J �s r D"t-r <br />;ontractor s Name License #A7j Phone <br /> .j x. <br />:'YPE OF WORK (Check) : NEW WELL / DEEPEN /_/ PRECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /% PIMP REPAIR /—/ PUMP REPLACEMENT /-J { <br /> Other /"I/ <br />)ISTANCE TO NEAREST: SEPTIC TANK SIP SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /—ZFY � OTHER , <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 /> 4w; 'Domestic/private 't Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Ce/� f'w <br /> Disposal :( Other Other Information <br />—Geophysical _ Surface Seal InstaIled By;- _- 1!�/ IQ <br /> - - V. <br />'UMI) INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: /T/ State Work Done <br />'UMP REPAIR: / / State Work Done <br /> I'STRUCTION. OF WELL: Well Diameter Approximate Depth <br /> 4 Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> f.ter completion of my work onia new well, I will" furnish the San Joaquin Local Health District a <br /> ELL 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 /> ZIOR TO GROUTI G AND A FINAL INSPECTION. i <br /> IGN1-DA TITLE <br /> 1 OT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> MASE I <br /> 'PLICATION ACCEPTED BY DATE <br /> )DITIONAL COMMENTS: <br /> PHASE II E ION PHASE III/FINAL INSPECTION <br /> 'SPECTION BY I UTE _ - D ']? ""INSPECTION BY DATE , <br /> P 14 91.1)ti <br />