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! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFF,IC` E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION-OR PUMP PERMIT Permit No. <br /> / HIS PERMIT MIRES ]_ YEAR FROM DATE ISSUED Date Issued !/�3-76 <br /> (Complete In Triplicate) -� 0575--?_r 0S_U <br /> iL Application is hereby made. to the San' Joaquin Local Health Distri6t 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 egula s orf a San Joaquin Local Health District. <br /> 4 JOB ADDRESS/LOCATION 4%1V Z70-9,V13- _X� Ogr"•5 SZWEw <br /> i <br /> CENSUS- TRACT <br /> Owner s N m SClI97S <br /> Phone J,31r_! �d <br /> Address / 7' ej000'71145f /00--7. <br /> � City <br /> Contractor's Name 7- /-7" License ���3 PhoneA4eZr'4*16 <br /> i TYPE OF WORK (Check) : NEW WELL/�J DEEPEN RECONDITION DESTRUCTION <br /> r 'PUMP INSTALLATION '/ / PUMP REPAIR "/ J PUMP REPLACEMENT /_7 <br /> Other <br /> DIST1§jjk NaRAF SEPTIC TANK SEWER LINES PIT PRIVY <br /> EWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL N <br /> INTENDED USE.7 TYPE OF WELL CONSTRUCTION SPECIFIC TARO S ' <br /> IndustrialC�Tool. Dia. of Well Excavation <br /> Domestic/private Drilled . Dia. of Well Casing <br /> Domestic/public Driven . . `*'Gauge of Casing <br /> Irrigation Gravel Pack ` s #Depth of Grout Seal <br /> k Cathodic Protection Rotary Type of Gro <br /> Disposal Other Other Inforon <br /> Geophysical -� � Surface a I stalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type- of Pump H.P. <br /> PUMP REPLACEMENT: / / S tate Work"Dore <br /> s. PUMP 'REPAIR: /. /.. State-Wo ?one' " _- _ �,: . " •. <br /> -- �� - - <br /> DESTRUCTION OF WELL: Well Diam ter ; Approximate Depth <br /> Describe tie an rocedure <br /> I hereby agree toply it 1 aw a regulations of the San Joaquin Local Health District <br /> and the State of al fo is p Vining or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion w rk on 4& new we 1, I will furnish the San Joaquin Local Health District a ! <br /> WELL DRILLERS' REP T. of the well and notify them before putting •the .well in use. The above <br /> information is true to the best of myknowledge and belief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING- AND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> " D W PI-OT PLAN ON REVERSE SIDE), c - -—,r,- - ,--.��� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 r ti CEP <br /> EPT �:$p,Y <br /> APPLICATION ACD o/,5JDATE - <br /> ADDITIONAL COMMENTS: <br /> keet PHASE II G N PECTION PHAS Ur /FINAL INSPECTION ! <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> .., <br /> E H 1426 Rev. 1-74 , 376 . 2M <br />