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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. 77 / 7S Zd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,9 2 S_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 les and Regulations of the San Joaquin Local Health District.; <br /> JOB ADDRESS/LOCATION CENSUS TRACT " <br /> Owner's Name LO D COV E I�� Phone <br /> Address .— 2 1 3 VV I-R 1 pyN Rr--). _ City ,-R) 1'O tJ <br /> Contras torr's Name OW/VQ L-19N DI S License # Phone <br /> TYPE OF WORK (Check) : NEW WELL,,& DEEP _/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION � PUMP REPAIR/ / PUMP REPLACEMENT /_ G <br /> Other <br /> r <br /> DISTANCE TO NEAREST: SEPTIC. TANK /Qp-i-- SEWER TUNES /00 'T`- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �� CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY .L'INE - PRIVATE DOMESTIC WELL PUBLIC'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Industrial - `" Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing=-, L11 <br /> Domestic/public Driven Gauge of Casing C—, <br /> Irrigation _X Gravel Pack Depth of Grout Seal --- <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal - r Other Other Information <br /> Geophysical .,,. + i Surface Seal Installed B aWN� <br /> ' f y. 1 <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /. / State Work Done f <br /> DEgiRUCTION OF WELL: Well Diameter Appkoximate 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 /> ani the State of California pertaiir ng to or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaqujin Local Health District <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 GROUTI G D A FINAL INSPECTION. j <br /> SIGNED =_p _ y TITLE 0 WN E�_P_l <br /> -(DRAW PLOT_PLAN ON REVERSE SIDE) • <br /> F . DEPAR NT USE ONLY <br /> PHASE I } <br /> APPLICATION ACCEPTL- <br /> - �, _V /IJaT DATE <br /> ADDITIONAL COMMENTS: r ' <br /> _� ' PHASE=II=GROUT INSPECTION-r `- - -- - `PHASE I IN� �- INSPECTION" <br /> INSPECTION BY DATE A INSPECTION BY DATE��-%/�_7 <br /> .. UZ7 <br /> E H 1426 Rev. 1-74 - <br />