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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfirO 'FICE USE: , 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> JI. <br /> { �`APPLICATION,FOR.WELL ,CONSTRUCTION OR-PUMP PERMIT Permit No. �s 7�� <br /> i� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5- --7- <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> '` 33 s'• G44-ir"t t9-p� 2'F? �3a_ cls <br /> JOB ADDRESS/LOCATION I6 0 rCENSUS TRACT <br /> Jim <br /> Owner's Name Phone <br /> Address EICity <br /> i <br /> Contractor's Name t - --License # / d S/Phone <br /> 1 <br /> y.-_:..-'.+.�.T w. -.:,-r• - �s..x.�.qee: __ .'+.�.F•�.-.=..tea ..m -x'.�w.�r� ,-..--._r..z .-. _ z«.-s <br /> TYPE OF WORK (Check): NEW WELL/_)(T DEEPEN /_7 RECONDITION /? DESTRUCTION <br /> '•r PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f7 ^^ll <br /> a iii Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES C) �P.IT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL`£ PUBLIC DOMESTIC WELL <br /> INTENDED USE " -TYPE OF WELL" ,z CONSTRUCTION SPECIFICATIONS <br /> Industrial �� �� Cable Tool Dia. of Well:-.Excavation <br /> Domestic/private- Drilled Dia. of Wel]: Casing14 11 , <br /> Domestic/public 'i - .DvenGauge.of Casing- <br /> .),Irrigation Gravel„Packt Depth of Grout Seal <br /> Cathpdic Protection.- ' �. Rotary,- --.- -- Type of Gr'out'. <br /> Disposal - '' „ "`•Other_” Other Information <br /> Geophysical � <br /> r <br /> Surface Seal installed Hy! <br /> .PUMP INSTALLATION: . Conttact,or �+ <br /> Type of. }Pump <br /> H.P. <br /> PUMP REPLACEMENT: il, / State Work Done <br /> .,.P.XTMF._:REPAFR <br /> { ESTRUCTION OF WELL: Well Diameter Approximate Depth U <br /> Describe Material and Procedure ATv Fr , <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> s and the State ofCalifornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my;work on a new well, I will furnish the Saiz 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED ! TITLE' <br /> 1 » (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE ` <br /> ADDITIONAL COMMENTS: II <br /> P S II GROUT PECTION PHASA I I '' NAL INSPECTION <br /> INSPECTION BY ATE S'-i7, -;7D INSPECTION BY DATE 2- -� <br /> y <br /> 1 ' <br /> E H1426 �. <br /> --Rev �1-74 _ _ n `- 1-74 2M _ <br />