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1',, SAN JOAQUIN LOCAL NFALTY DISTRICT <br /> FOR OFFICE USE: q,� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �1 Telephone: (209) 466-6781 <br /> ,aAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77: 53Y <br /> clV563 <br /> J THIS PERMIT EXPIRES 1 YEAR 1'e�P: DATE ISSUED Date Issued (�-�_ 7L <br /> (Complete In Triplicate) <br /> application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .,dnd/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 /> /'f 555 <br /> .OB ADDRESS/LOCATION Oil S J?/7 CENSUS TRACT <br /> Owner's Name CAM & 6 QJ(sS _ Phone 4& !;kZ72-7 <br /> T � <br /> Address /LAS J S G i GLI S City <br /> p4 5v0'0 <br /> ontractor's NameQpf�l 4 gamaw, License ll Phone 3�, y i 9 J <br /> 'YPE OF WORK (Check): NEW WELL / DEEPEN %% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> v <br /> DISTANCE TO NEAREST: SEPTIC TANK 72' SEWER LINES PIT PRIVY u <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation v <br /> _X Domestic/private Drilled Dia. of Well Casing 11rjZ FcnrJue.rhjL <br /> Domestic/public Driven Gauge of Casing gr A C,Ai- 14/ah g&SID y <br /> Irrigation Gravel Pack Depth of Grout Seal A "A W4L <br /> Other Rotary Type of Grout 0 - <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materj,al and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd 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 /> =nformation is true to <br /> }} the best of my knowledge and belief. <br /> `SIGNED 11V da TITLE 6k ul �L14 Tngetce7 <br /> —� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> -PHASE I J1 <br /> APPLICATION ACCEPTED BY DATE -� I <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />