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_ /o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR GFFICL� USE � 1 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27- 03) w <br /> THUS PERMIT EXPIRES' 1 YEAR FROM DATE ISSUED Date Issued 3_//= 77 . ! <br /> (Complete In Triplicate) +4;D; 247- /...yo-Z6. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and tt a Rules and Regulations of th S Joaquin Local Health District. <br /> Lcr���,1� <br /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Owner's Name Q�dAl yPhone <br /> Address <br /> II ` <br /> 0 � .l�. � City <br /> Contractor's Name License # 1.2d2Q U Phone _LM4 (j e <br />_TYP-E„OF}WORK(Check)-:,_NEW.:WELL_:;_//, / DEEPEN-/�/y,:RECONDIIION�,/:%DESTRUCTION <br /> PUMP :INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> O the /_7 7 �- <br /> r, <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 0 SEWER LINES PIT PRIVY . <br /> SEWAGE.IDISPOSAL FIELD CESSPOOL/SEEPAGE` PIT OTHER -" } <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I }I <br /> INTENDED USE HYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br />�. Industrial ;IM Cable Tool Dia. of Well Excavation <br /> Domestic/private 11- Drilled Dia. of Well Casing _ ►��� . <br /> _Domestic/public .I1 Driven Gauge of Casing . }a1I <br /> �._._� ��--�-G - ]]�ptl��i��Gsr3'��Sea� --�= - - � - _-`rte---,•-- �y" ; <br /> __ Catbgdxc Pzotec.tion._-�L Rotary _ . '.;_,_'Type_of_Grout <br /> Disposal IM TT Other Other'Information <br /> Geophysical �* = y{ -Surface Sealy:B 1� <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump";'' _ _ _ _ _ <br />' PUMP REPLACEMENT: / / `IState Work Done ; ` <br /> PUMP .REPAIR: State Work Done <br /> �M. <br />.DES-TRUCTION OF WELL: . Well b ameterw _ _ _"_L 7 -7 Approximate Depth, y <br /> Descrlbe Material and Procedure <br /> # <br /> I hereby agree to comp ly ,with, h, 1.1aws 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 th ..San Joaquin Local Health District a <br /> WdL 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. ' IyWILL CALL FOR A`GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL -INSPECTION. <br /> TITLE <br /> SIGNED •, . , . �h. � C/►„n,�� , <br /> i . (DRAW PLOT PLAN ON REVERSE SIDE) t <br /> FOR MPARTMENT,,USE ONLY <br /> PHASE I: ' "y <br /> APPLICATION ACCEPT A`W077 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE .I.I.GROUT- INSPECTION PHASE III N INSPECTI N <br /> INSPECTION BY,. :. k} DATE INSPECTION BY DATE ,� <br /> .ti. <br /> E H 1426 Rev. 1-7 4 2I <br /> - --- <br /> ,_ _ Vw 1/7] . <br />