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SAN JOAQUIN LOCAL HEALTH DISTRICT - /{ <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 'k A�Ly� es-/-j <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 /> C 3Sa C, 116 .lila�-. <br /> JOB ADDRESS/LOCATION Stockton Junior High School UU CENSUS TRACT <br /> Owner's Name Stockton Unified School District Phone 466-3911 <br /> Address 1149 N ElDorado St. , City Stockton <br /> Contractor's Name W. W. Vernon Co. , Inc. License # 283 759 Phone 948-9642 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /x-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / / <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION .OF WELL: Well Diameter Eight (8) inches Approximate Depth 100 fee <br /> Describe Material and Procedure Cut off casing three ( 3) feet <br /> below ground, fill with sand with top 50 feet filled with c c <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distric <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 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE President <br /> (DEZAW. P T PLAN 'ON REVERSE SIDE) ' <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Q um DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE I EC PHA S AL INSPECTION <br /> INSPECTION BY DATE b,1V INSPECTION B DATE/ E - <br /> /76 . 2m <br /> E H 1426 Rev. 1-74 <br />