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SAN JOAQUIN LOCAL HEALTH DISTRICT µ <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77- G <br /> THIS PERMIT- EXPIRES l YEAR FROM DATE ISSUED Date Issued 3-,/i%`7") <br /> I7lia+ - (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District -for a permit to construct'... <br /> ication is made .in com <br /> nce with San Joaquin <br /> and/or install the work herein described. This appl P <br /> 4 County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ / Z '�/_ S y���1 Pool/ CENSUS TRACT <br /> Y <br /> .Owner.'s Nam A41 I Z F WFA 0 Phone :!!!F .49" <br /> Address a I -5Al U2"_11t, City I <br /> Contractor's Name Al C-, - _ License #;Zgj27WPhone &-9947- <br /> TYPE <br /> S' -TYPE OF WORK- (Check): NEW WELL.& DEEP•EN -/? RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP,INSTALLATION ff PUMP REPAIR/ / PUMP REPLACEMENT f T <br /> Other <br /> DISTANCE TO NEAREST:_ SEPTIC TANK- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYILINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 'Tool Dia. of Well- Excavation 12 ", <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . T- --�. 8. g <br /> /pbi <br /> . . -, Driven..._. �,.- . Gau a_of Casin �. C�:.....�.q•. <br /> Irr gat on Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - _ Rotary Type of Grout -------, _: <br /> Disposal a. Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Cont=ractor _ C •5' <br /> Type" of rump SUl3/aa��'S//�L H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUNF .REPAIR: / / State Work Done <br /> DES•'TRUCTION _OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _ - -- <br /> k. <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 Distri.ci a <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well in use. The aboye <br /> r information is true to the"best of- my knowledge and belief. I WILL CALL FOR A GROUT 14SPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE LE <br /> D W PLAN 'ON REffRSE SIDE }` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE1� : <br /> s ADDITIONAL COMMENTS: <br /> PHASE II GROUT iN-EPECTION PRASE P'IN INSPECTION <br /> NNSPECTION By— DATE INSPECTION B ATE A d� <br /> 1 <br /> 3/76 <br /> H' lk2b Rev. 'h7k '° <br />