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e&"yp SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE U E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7Z-IVR P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1-J8'-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 -an Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION CENSUS TRACT /`fS-Z2,30-D'� <br /> N <br /> Owner's Name ----•___ �'i �J i"a 40rPhone!�?� . -- --- ---- -- <br /> Address Q City _ f <br /> Contractor's Name Vp License #l 3.7 `Fhone 766-- : <br /> k, <br /> :r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <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 i <br /> Domestic private Drilled Dia. of Well Casing <br /> Dotaes.t � �#blic Driven Gauge of 'Casing __ k <br /> - Irgaori Gravel Pack Depth of Grout Seal <br /> - Caliodc 'Prot"sRotary Type of Grout <br /> Disposes] Other Other information' O <br /> Geophys 'cal Surface Seal' Installed By:' <br /> �r <br /> PUMP INSTAdAZ'ION: Contractor Oki a <br /> r, Type of Pump H.P. f C1 9, <br /> PUMP REPLACEMENT:, /% • State Work Done <br /> PUMP .REPAIR. /C/ State work Done, d � .,/ �",� .� <br /> DES-TRUCTION, OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure. :' <br />-1 hereby agree to comply with all laws and regulations of the San Joaquic` 4 <br /> al Health Districts \ <br /> and the State of California pertaining to or regulating,well-construction. FIFTEEN DAYS <br /> after completion of my work on a new well, I-will furnish the San Joaquin, Local%lth District <br /> WELL DRILLERS-4EPORT of- the well and notify them before putting the well in use. The above <br /> information is true to the best: m owledge and belief. I WILL CALL-FOR A GROUT INSPECTION <br /> PRIOR TING AND A I SPECT a = <br /> SIG TITLE <br /> b T PLAN E. FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE :I - <br /> APPLICATION ACCEPTED BY DATIE -_- <br /> ADDITIONAL COMMENTS A } <br /> " k. PHASE II GROUT INSPECTION. INSPECTION <br /> INSPECTION BY DATE INS TE <br /> , .. - ,• Mix '. '� <br /> E H 1426 Rev. 1-74. 3/76 . <br /> :� <br />