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/ /� <br /> XJ� <br /> �- fr Jr. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 3 P <br /> FD�FPICE USE: 1601 E. Hazelton Ave, > Stockton, Calif, <br /> Telephone-;' <{20)`44.fi'6.=6781 �rJI� <br /> PLICATION FOR 'WELL. CONSTRUCTVON-=OR PUMP P , T Permi No. �57% <br /> THIS PERMIT-' EXPIRES, 1� 'YEAR•� FROM DATE,ISSUED! Date Issued <br /> . ..(Oompletje. In T-i#flc4te) <br /> Application is hereby,mad-e•-:to ,the-Sala Joaquin. Local He'al`th 01s:tilet,'-fbr:,a permit to construct <br /> and/or install the work herein described. Thisapplicafton, ls' made' in compliance with San Joaquin <br /> County,'Or-dinance`:No., 1862-dnd.­the•Mlds- sn'd Regulations-of,:--the, SanJ;Joaquin, Local-Health•-District.t= <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Dame ��� /01. �_ Phone _6`7 2...6, <br /> Address 3 z ...._ z. 3 9 City •`✓ cy p� <br /> Contractor's Name Dicense �� /7tS Phone, 76 <br /> i <br /> TYPE OF WORK (Check) : NEW ITELL b_�Y DEEPEN / :/ RECONDITION_/ / DESTRUCTION <br /> PUMP? INSTALLATION PUMP REPAIR / / ; PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC`"TANKf50 SER WELINES'' P T -PRIVY <br /> .._. SEWAGE .D1S1QSAL FTELb 5`5 CESSPOOL/SEEPAGE PIT' OTHER <br /> r <br /> PROPERTY; LINE PRIVATE DOMESTIC WELLI�- PUBLIC; DOMESTIC WELL -.] <br /> INTENDED ,USE "TYPE OF WELL -CONSTRUCT,,.ION' SPECIFICATIONS � - <br /> Industrial 1.77777Cagle Tool- Dia.-, of Well Excavation a C <br /> Domestic/private Drilled Dia. of;,Well Casing <br /> Domestic/public ;Driven Gauge of Cdsing PVC /150 <br /> Irrigation :.. .. :.. .. ...Gravel Pack D.epth. .of. .Grout Seal <br /> Cathodic Protection <br /> __.K_ . Rotary Type, of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B /VEiC i <br /> PUMP INSTALLATION: Contractor 5,41-1 E5 Q/CL 6.6 <br /> Type of Pump 15Uj?M• _ - - --- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF,WELL: = . Well Diameter Approximate Depthl. <br /> Describe Material and Procedure <br /> I hereby agreeto .comply with all laws and regulations. of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulatin& well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, ,I will furnish the San Joaquin Local Health District a <br /> WELL D7i' <br /> S REPORT of th ell and: notify them before putting the .well .in use. The above . <br /> info mais true th best of my.knowledge and belief. I WILL .CALL FOR A GROUT INSPECTION <br /> PRID TJfi G A <br /> SIGNED TITLE f <br /> (DRAW PLT PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHAS <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> -PRASE_IVGROUT INSPECTIONp P E II/FINAL INSPECTION <br /> INSPECTION BY DATE 7-/7-.7 0 INSPECTION BY r DATEZ <br /> /;-V <br /> - <br /> E 1426 Re{r. 1-74 ..l ! I GaG�1i✓ '° O2 �G <br />