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Y !/ SAN JOAQUIN FOCAL-,HEALTH DISTRICT r <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. / _7LAS4,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10-lf- <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 Local Health District. <br /> 30B ADDRESS/LOCATION /_-9p6 11�ti,: CENSUS TRACT <br /> a Owner's Name Phone , XR5�:�a-81 1 <br /> Addressi b ad t?61 City: - Egchl d-hi- <br /> Contractor's Name License # UAW Phone 13C r 2-6 <br />{ <br /> TYPE OF WORK (Check) : NEW WELL ZX7 }DEEPEN /7 - RECONDITION 17- DESTRUCTION =.. - ---- <br /> PUMP INSTALLATION / PUMP REPAIR /7 PUMP REPLACEMENT <br /> ---- — — — <br /> _-Other / ./. a . .;, s .... <br /> .DISTANCE TO NEAREST: SEPTIC TANK 4 SEWER"LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT -OTHER --�' <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE:,OF •WELL `� CONSTRUCTION SPECIFICATIONS. <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private -- 'Drilled ° Dia: of Well Casing ., <br /> Domestic/public FDriven f• A�" Gauge of 'Casing <br /> - Gravel Pack ""'�F <br /> Irrigation DepuRofGrout_Seal_.__. - <br /> �1 - Cathodic Protection !Rotary f . '..E �-Type-iof�.Grout__- <br /> Disposal Ot1ier Ot6&r Information' ' <br /> t Geophysical Surface -Seal Installed 'By: i-,#lfIL M CJ <br /> PUMP INSTALLATION: Contractor ,-, d `" `' ""�r" �� -- -!�!►/9t"�►1 -r <br /> Type of Pu <br /> ttip �r -;.�, ,. H.P. <br /> PUMP REPLACEMENT: <br /> / / State .Work Done ."' <br /> — <br /> 1 -- <br /> PUMP :REPAIR: / / State -Work Dane <br /> DES;TRUCTION OF WELL: Well Diameter; ,Approximate Depth <br /> ' Describe Material and Procedure <br /> ' I hereby agree to comply with all ;laws and regulati6ns ;of the San Joaquin Local Health District '\ <br /> and the State of California pertaining to or regulating'_well "construction, Within FIFTEEN DAYS <br /> aftercompletion of my work on.anew well, I will furnish the San Joaquin Local Health District <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'oV my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> yPRI0T0 GROUTING AND A VINAL INSPECTI <br /> R_ ON. <br /> 'SIGNED "' i, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> _i FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> � APPLICATION' ACCEPTED BY, A4_-1L11544` DATE el a T <br /> ADDITIONAL COMMENTS: ` ; <br /> ' <br /> PHASE'JI GROUT INSPECTION PHAS II INSPECTIO <br /> INSPECTION BYDATE INSPECTION BY//,,, DATE 44 <br /> R R ILM 1_77A _, Zt '75 2M <br />