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CdL 1G' ° SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE O, FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />' Telephone: (209) '466-6781 - <br /> APPLICATION <br /> 209) '466-6781APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77,a-Q fp, <br /> THIS PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED Date Issued <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q: 3��/�l�/� Ti/ ../�Y/mil, ���;FfCEN'SUS TRACT <br /> . . <br /> Owner's Name A11,0 "'Phone <br /> Address h �fG1 City s �. <br /> Contractor's Name ,. License #xAL7i�, -Thone <br /> I TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / /• RECONDITION /_/ DESTRUCTION /7 <br /> ,PUMP INSTALLATION '/ / PUMP REPAIR E/ PUMP REPLACEMENT /7 <br /> Other! / T . . . Cv <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> CC Irrigation x _ . ...� Graved Pack. Depth. of Grout ,Seal.. <br /> Cathodic Protection .,Rotary,.- Types of Grout <br /> Disposal f; . Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ' y <br /> Type- 6f Pumpf . _ H.P. C-) <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done (a r G - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agxee '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 /> i ,. <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 I S E 0 <br /> SIGNED TITLE ''. <br /> RAW PLAN ON FRSE SIDE <br /> FOR DPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1X17 7 <br /> ' ADDITIONAL COMMENTS: <br /> r PHASE II GROUT INSPECTION I PHASE III/FINAL INSP CT ON <br /> INSPECTION BY DATE INSPECTION BY DATE 3,9-/&-77 <br /> � i I <br /> h E H 1426 Rev. 1-74 376 2M <br />