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SAN JOAQUIN LOCAL 1111ALTH- DISTRICT <br /> FOR OFFICE USE: '" " 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELE.CONSTRUCTION OR PUMP PERMIT Permit'FNo. <br /> r ;;17-AO92)a <br /> I� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Ii'sued <br /> i (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 /> I� <br /> h JOB ADDRESS/3NI / ��r CENSUS TRACT <br /> Owner's Name , L1���-��l�S Phone <br /> Address City <br /> Contractor's Name License --' _hone <br /> F <br /> i <br /> TYPE OF WORK (Check) : NEW WELLf DEEPE / / RECONDITION / DESTRUCTION /711 W <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /?� <br /> DISTANCE TO NEAREST:: SEPTIC TANy,. SEWER LINE&A PIT PRIVY�_,­ ;d <br /> ` (SEWAGEDISPC AL TELV— " SSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 4 <br /> -INTENDED-USE- -- TYPE-OF-»-WELL-— .-4----CONSTRUCTION-SPECIFICATIONS <br /> Industrial -Cable Tool Dia: of Well Excavation _z <br /> Dome stic/p iris V4te� _ Drilled D a. of Well Casing <br /> Domestic/public r Driven Gauge ,of Casing /2� <br /> Irrigation Gravel Pack�__Depth- of Grout Seal _ e0 <br /> Cathodio,-Prot6ction Rotary Type of Grout <br /> Disposal ' "Other - Othet'llnformation 'M <br /> E Geophysical —Sdrface Seal Installed B <br /> PUMP/INSTALLATION: Contractor; L— . ,_b-v V`YKA/J2 s -� <br /> T: <br /> Type of ?Pump HIS P. <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP'.REPAIR:� State Work Done <br /> roximate Depth <br /> DESTRUCTION OF WELL: Well Diameter pP p <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. ij. The above <br /> ' information is true to the-best of my ,knowledge and. elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> E SIGNED T TLE <br /> I L L SE SIDE) <br /> FOR DEPAR NT USE ONLY 9' <br /> PHASE I DATE �� '7 <br /> APPLICATION ACCEPTED BYs� <br /> ADDITIONAL COMMENTS: M <br /> PHASE II PROUT INSPECTION PHASE. III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> - wC�e4 ^o �^ .�,� 3/76 2�* <br /> E H 1426 Rev. -1-74 �� <br />