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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date Issued 3-IX- 7 7 <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 fFA L;4/v R40.!. 5e2 , of Co()AIrV DSPir,9'G CENSUS TRACT <br /> r RD. <br /> 4 <br /> Owner's Name C G dRz G Phoner7/`¢ 1'Z$`yZ6O _ <br /> Address /-/M _AV f�D.4� _- City E916AICR CIANid <br /> Contractor's Name -- - Q+�G AVAIA1 0161C. License #200 Phone !ZA $_SL_7 <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 ! <br /> PUMP INSTALLATION '/ / PUMP REPAIR/ / PUMP'REPLACEMENT 1 ! <br /> Other - <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK 3001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEZ'6'PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool. Dia. of Well. Excavation <br /> O°' a <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing Y _1Z 6A4 _ <br /> Irrigation 1 Gravel Pack Depth of Grout SealS-6-9 } <br /> Cathodic Protection y_ Rotary Type of Grout _ ,,4A10 e G,e.-w FA,r <br /> Disposal r Other Other Information <br /> Geophysical Surface Seal Installed By: iV'O,4C/C <br /> PUMP INSTALLATION: Contractor Act< J?j2AIR S ^ <br /> Type of Pump SO ZZM422S/ H.P. <br /> PUMP REPLACEMENT- / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> 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-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A F NAL 'INSPECTION. <br /> SIGNED TITLE <br /> D W POT PLAN ON REVERSE SIDE) 77 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />-APPLICATION ACCEPTED BY � � DATE 3-18-7 ? <br /> 'ADDITIONAL COMMENTS: k <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 , . . . , <br /> 3/76 <br />