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SAN JOA(4111N LOCAL HEALTH DISTRICT <br /> FOF _UFF%E USE:- 1601 F. Hazelton Ave„ Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION VR PUMP PERMIT Permit No. ?7-x•3 6 Y <br />� <br /> THIS PFR_P711' EXPIRES ]. YEAR FROM DATF. ISSUED Date Issued //>S_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 DistL:^_t. <br /> i JOB ADDRESS/LOCATION R/s 7TictnMt•.� �s:'G E Tot_kfU�L CENSUS TRACT <br /> Owner's Name Eos e i Harb'. J Phone _ <br /> Address fit 'i <br /> Contractor's Name _ OZZJ,� /Ga. OR,//,,v �Co License 9.— Phone^7-W.2S�� .. <br /> 0. 6 <br /> TYPE OF WORK (Check) : NEW WELL /;R7 DEEPEN / RECONDITION /7 DESTRUCTION /7 <br /> / 3 a <br /> PUMP INSTALLATION / / PUMP REPAIR / FUW REPLACEMENT /7 <br /> (bwt/ ,21 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK S►o SEWER LINES 0 PIT PRIVY' ' <br /> SEWAGE DISPOSAL FIELD %O-0 CESSPOOL/SEEPAGE PIT •-e— OTHER <br /> PROPERTY LINF.ID:'tPRIVATE DOMESTIC WELL =!' PUBLIC DOMESTIC WF.L ,7:; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too]. Dia. of Well Excavation <br /> _.r Domestic/private Y Drilled Dia. of Well Casing <br /> Domestic/public Y`— Driven Gauge of Casing //•o O!/ PyC v <br /> _ Irrigation L Gravel Pack Depth of Grout Seal s—d <br /> Cathodic Protection Rotary Type of Grout ele n , T-- <br /> Disposal Other Other Information 1, <br /> Geophysical Surface Seal Installed By: //r ase z3F,/Z. f} <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> a Describe Material and Procedure <br /> C <br /> J <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 /> j after completion of my work on a new well, 1 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 I, <br /> information is true to the best of my knowledge and belief. 1 WILL CALL FOR A GROUT INSPECTION <br /> 's PRIOR 'CO GROUTING AND A FINAL INSPECTION. <br /> TITLE �y y¢.�yti <br /> DRA4J PLOT PLAN ON REVERSE SID <br /> S FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,6 <br /> ADDITIONAL COMMENTS: ��1��' <br /> PHASE II GROUT INSPECTTON PHASE II FINAL INSPECTION <br /> INSPECTION BY '- DATE /9_ .- 7 INSPIXTION RY DATE �7 <br /> 6,177 2M <br /> E H 1426 Rev. - I-74 <br />