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SAN TJOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 101. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 }� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No� 4"V®a <br /> THIS PERMIT EXPIRES l YEAR. FROM DATE ISSUED Date-- Issued . , ,7 <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 Jo quin Local Health District. <br /> JOB ADDRESS/LOCATION t?" '' �{ �li, ' ` �' +'� ='�' NSUS TRACT <br /> Owner's Name ,s= :� ' .ay'J rif ,; % r Nv"� , "r:; s {, Phone <br /> Address '✓' -!' _." f City" <br /> . » � . <br /> { ,,. <br /> T :,_, - :' � x , License �� .s✓' Phornez, ' 'i ":�- ;;� <br /> Contractor,'s ,Name. -, �- '` ` a1 ". fir;�t. 3 <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN/ / RECONDITION ,/ /, ,DESTRUCTION /-7 <br /> PUMP.- INSTALLATION / / PUMP REPAIR- /-/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK AA noY SEWER LINES r art ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �F CESSPOOL/SEEPAGE PIT OTHER <br /> y <br /> PROPERTY LINEet' PRIVATE DOMESTIC WELL __ PUBLIC DOMESTIC WEL a <br /> _' <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 Driven Gauge of Casing <br /> 55-0 <br /> E )( Irrigation Gravel Pack Depth of Grout Seal _ '- 4 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. <br /> Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor V� cA" ` '`r`x/j <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State,Work Done <br /> 1 , p <br /> PUMP .REPAIR: r / / State Work Done <br /> r' DESTRUCTION OF WELL: Well. Diameter _ Approximate Depth <br /> ' Describe Material and Procedure <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 well, I will furnish the San Joaquin Local Health Di'strkct t <br /> WELL DRILLERS REPORT of -the well and notify them before putting thewell 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 IN5P CT IU - <br /> SIGNED r` „„~y �: -.. x.� • TITLFt' / <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> OR D PARTME IT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE �7 a <br /> f ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FI AL INSPECTION '- <br /> INSPECTION BY DATE INSPECTION BY DATE l � <br /> ofl.7 2M <br /> u 117E Da . '1_7fi X <br />