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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 //_ 6 <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued <br /> /-e) I2 <br /> Application is hereby made to the San(CompleteJ aquin Lo alIn rHealthtDistrict for a <br /> F permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health Distract. <br /> JOB ADDRESS/to##p"N Z-? Z <br /> CENSUS TRACT <br /> Oalner's Name / <br /> �C�f Phone <br /> Address <br /> City <br /> Contractor's Name S <br /> ' License 162 <br /> � ��Phae <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION - - <br /> PUMP INST LATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK f- SEWER LINES �p-#—PIT PRIVY r-- <br /> ! I SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT ZQ /--OTHER <br /> /�.._ <br /> PROPERTY LIN RIVATE DOMESTIC WELLf PUBLIC DOMESTIC WELL i- <br /> INTENDED USE _ TYPE OF WELL <br /> Industrial , CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, o_f Well Excavation J / <br /> Domestic/private Drilled <br /> Domestic . ublic. Y- _ - ;Dia. of Well Casing_ ' <br /> f /p �. -Driven 1-.j .,Gauge._of;Casing' 2 <br /> .I Irrigation ac ' <br /> Gravel Pack Depth of Grout Seal 4- <br /> Cathodic Protection Rotar <br /> Disposal - -a- -` - y Type of Grout <br /> ather"�` Other_!nformation <br /> Geophysical <br /> f ` Surface Seal Installed By: <br /> PUMP INSTALLATION: s <br /> Contractor6'�: .`� <br /> r- Type of Pump' , <br /> p _ H.P, <br /> PUMP REPLACEMENT: ' or� +� <br /> f _ / State Wk�Done <br /> PUMP .REPAIR: State Work bone <br /> DESTRUCTION OF WELL: .I Well Diameter— <br /> _M/ ' r ate D6 ' <br /> Describe Material and Procedurepth <br /> s t <br /> I hereby agree to comply with all laws ad�regulations of 'the San Joaquin Local Health District <br /> and the State of California pertainin <br /> after completion of my work on g to or regulating well construction. Within FIFTEEN DAYS <br /> 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 knowled e and belief. . <br /> PRIOR TO GROUTING AND A FINAL INSPECTION I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED = <br /> TLE <br /> LOT L ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEP MENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE /.z 7 <br /> a <br /> PHASE II� ROUT INSPECTIO <br /> INSPECTION BY DATEP E I/ INAL INSPECTI <br /> INSPECTION BY <br /> - DATE a C 78' <br /> E H 14'2 e .• ' 1- s;�i� <br />