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SAN JOAQUIN LOCAL HEALTH DISTRICTJob Completed <br /> FO$ September 1976 <br /> rOFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR,WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> THIS PERMIT IRES 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 applicationgis 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 <br /> NW Corner Lit:Aead & Tracy Blvd. CENSUS TRACT <br /> Owner's Name R. C. Kennedy I Phone 209/835-7439 <br /> Address 27867 Tracy°Blvd. City Trace <br /> Contractor's Name Western, WeU Drill, a Co., Ltd <br /> - .„' License # 257.82 Phone 295-4„312 <br /> TYPE OF WORK. (Check): 'NEW WELL I'7- ,DEI$PEN. <br /> I-T- ,RECONDITION:.XDESTRUCTION /7 <br /> PUMP INSTALLATION /_7_ <br /> PUMP REPAIR /�_PUMP REPLACEMENT /'7 <br /> Other ,117 Instal 0 T. gravel arounom casing; TV log; clean perforations, k <br /> a: ,M <br /> DISTANCE TO NEAREST: SEPTIC TANK 71 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 WELLCON5TRUCTION SPECIFICATIONS <br /> Industrial CablelTooZ Dia, o£ Well Excavation <br /> Domestic/privateDrilled Dia. of Weil Casing <br /> Domestic/public I! Driven Gauge of Casing <br /> Irrigation , Gravel Pack Depth of' Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other. Other Information . <br /> Geophysical <br /> Surface Seal Installed- BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1� S.P. <br /> PUMP REPLACEMENT: CI State Work Done ° <br /> PUMP !REPAIR: L'-7 State Work Done _ <br /> ES;TRUCTION=OFTWELL: <br /> Well' Diam_eter - _ Approx-imate'Depth <br /> Describe Material and Procedure <br /> F <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 GROU D A FINAL INS' ION. <br /> SIGNED I�. TITLE Vice President <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> JPHASE I FOR DEPARTMENT USE ONLY <br /> - _, _ <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONI PHASE III INAL INSPECTION <br /> INSPECTION BY DATE J INSPECTION BY DATE 7 <br /> y <br /> ,E H 1425 Rev. 1-74 1- <br /> 74 2M <br />