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A. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS. OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> r <br /> Telephone: (209) 4664781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-/V&/ <br /> 77- <br /> TH IS <br /> 7-THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _7 7 <br /> (Complete In Triplicate) <br /> Application is hereby made -tp 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 rhe Rules and Regulations of the San Joaquin Local, Health District. <br /> JOB ADDRESS/LOCATION Z7- sec.'],6Aj CENSUS TRACT . <br /> Owner's Name Phone ' <br /> CC <br /> Address City 74L <br /> i <br /> Contractor's Name ��� � T^ License # _9,607g�/Phone9 f f <br /> ' 1 - <br /> TYPE OF WORK (Check) : NEW WELL' jW( DEEPEN ' / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP _REPLACEMENT /� <br /> Other,./ <br /> DISTANCE TO NEAREST: `SS EPTIC, TANK SEWER LINEPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �"., ,'..'.4 -NTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> '-Industrial Cable Tool Dia. of Well Excavation /U <br /> f 'Domesric/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J 2. <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> -- Other Rotary Type of Grout g AC& fYj! .1S <br /> Other Other Information ? <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: /4/-.S tate Work bane <br /> PUMP U,PAIR: / J State Work Done <br /> ,DFgTRUCTION OF WELL: Well Diameter Approximate Depth ; <br /> Describe Material and Procedure <br /> 3 <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 /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The abov <br /> informat' is rue to the. best of my o ledge and belief. <br /> SIGNS 44 lJ�'`-� TITLE <br /> # JXMW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _...._.,., <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE kI GROUT INSPECTION PHASE III/FINAL. NSPECTION <br /> INSPECTION BY j �� <br /> DATE -/ T.'7']' INSPECTION BY DATE �6 `7d'' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �/7 iim <br />