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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0fi-OFr1TCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 �/�L <br /> APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No. 77 /W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ���7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> PP y q <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 �Jj,/ Y2�- ,Q®s�,,�,�.- ,_gam _ -. <br /> CENSUS TRACT <br /> Owner's Name /�¢� ,/e r-c1/ - -_ Phone 6 _ <br /> Address ^T_2XI 4(3,,, kos`.r� M ,?C/` _ - -- City c <br /> Contractor's Name 6wev &OA, e pat-141, License �260_ Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / j PUMP' REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK !�S SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD _es.- CESSPOOL/SEEPAGE PIT /ad* OTHER <br /> PROPERTY LINEJO_PRIVATE DOMESTIC WELL/5:_ PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _-ate <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ 6F/ <br /> Irrigation Gravel Pack Depth of Grout Seal -.5792 -` <br /> Cathodic Protection V Rotary Type of Grout <br /> Disposal Other Other Information — <br /> Geophysical Surface Seal Installed B :X Q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump __._._ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate :Depth <br /> Describe Material and Procedure <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 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 GROUTING AND A FINAL INVECTION. <br /> SIGNED ` TITLE _ _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY° " <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: _ 5 <br /> PHASI GROU I SPECTIO PHAS II/FI INSPECTI N ` -7 <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> aD 6 ' o ` 3/ '^ 077 _ 2M <br />