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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No/ Z400 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 177 <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 and Regulations of the San Joaquin Loral Health District. <br /> JOB ADDRESS/LOCATION1 y � CENSUS TR -C�I -� " <br /> Owner's Name LL-6t- ^ C3 i __9Z4&_ - Phone 3 cl , <br /> Address <br /> Contractor's Name � � <br /> License Jfy��hone ,-6 <br /> TYPE OF WORK (Check) : NEW-WELL—/�--DEEPEN -/_/RECONDIT ON%%"' DESTRUCTION' /_J <br /> PUMP INSTALLATION /`PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DT'STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �d PROPERTY LINE -- PRIV.ATE._DOMEST.I.G.WELLY-' _P_UBLIC_DOMES.TIC WELL � <br /> INTENDED USE TYPE- OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � , ._Cable Tool -.3 ` Dia. of Well Excavation <br /> Z,----EFo_mes tic/private --,->, Dri'11ed Dia. of Well Casing r/ <br /> Domestic/public �/Driven . Gauge of Casing' <br /> Irrigation sr Gravel Pack.' f Depth of -Grout S 1 (t,, <br /> Cathodic Protection - �tary Type- of 6�out <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMi?. INSTALLATION: Contractor _® <br /> Type of Pum <br /> PUMP REPLACEMENT_: State Work Done � <br /> PUMP .REPAIR: . .i <br /> State Work DoneGA11o � DT.F}iNQ <br /> DES.TRUC`TibN,OF WELT: Well Diameter' Approximate Depth' y <br /> � . <br /> DdscribMaterial and Procedure f <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 we1T, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of._thh 'we,11-and notify them before putting the .well in use. The above <br /> in ation is true to the lies t my knowledge ,and'-"berief. I WILL CALL TOR_A�GROUT INSPECTION <br /> PRIG OUTING ANDA FI PE I <br /> SIG NED4:� �� <br /> TITLE '1 r� .g,u <br /> AW Pig'T" PREVERS <br /> DRLAN 'ON RE FRS E S ID <br /> P I _,/FOR`DEPARTMEXT USE`ONLY • " <br /> APPLIC CEPTED BY DATE l <br /> ADDITIONAL COMMENTS: <br /> P II GROUT INSPE ON PHA II/FTN INSPECTIJDN j <br /> .. j <br /> INSPECTION <br /> BY DATE Q INSPECTION BY DATE I p `1 j <br /> E HVp 1426 Rev. 1-74 ��.: 7 '`r'" '`Q.ec.'�^ r dWy.Q'� 7�J ��6 2M C' ` <br />