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(d M r /e 7/az -00 , N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 'r• APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S-/7-77 <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 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 /d p L7� r M4,c�(�_ TDO h e CENSUS TRACT <br /> Cs <br /> —Owner's Name -err /0AADe7� lt.e e,f A i' Phone <br /> Address /+70 Y $ ], alt 7 � e, %Z� City lC4 , <br /> Contractor's Name „) �/ �x ✓ L•GJ License # t9�71,1'ghone c"ti -7L 26 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 2g PUMP REPLACEMENT /_ <br /> Other /_7 <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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> � Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / Lr H.P. t1U <br /> PUMP REPLACEMENT: / / State Work Done �. <br /> r <br /> PUMP .REPAIR: State Work Done , . <a• r < - <br /> r.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 knPwle ge a d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT G AND A FI AL INSPE y <br /> SIGNED <br /> (DRAW 0 PLAN ON REVE IDE <br /> 0 EPARTMENT USE ONLY <br /> PHASE I r /" <br /> r APPLICATION ACCEPTED BY i !'��/l 'cQ �U%•. DATE 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE IA GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE JV <br /> v <br /> F N 1G9(, Aa.. l_7G 11177 _ 2M <br />