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y 12-/Z/77 L�F7 � /�• / s �a/z/� .v'r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Cj j <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � L i�' P44—" <br /> Telephpne : x(209) 466-6781 Na <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMT Permit No. �7 1 <br /> 7 <br /> THIS PERMIT EXPIRES 1 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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . e C NSUS TRACT <br /> Owner's Name A1 i4f Z Phone <br /> Address City ''S c <br /> ��,.� <br /> Contractor_s_Namer. <br /> i ' <br /> TYPE OF WORK (Ch.eck.)_:.,,-,,,,,NEW WELL DEEPEN /�� - REGONI3ITIE)N` �, DESTRUCT-1-ON-/77. . r <br /> PUMP INr�sl�AL—LATION / / PUMP REPAIR / / Pt7MP REPLACEMENT /7 <br /> Other / 17 — - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> W. .a SEWAGE DISPOSAL FIELDC,. CESSPOOL/SEEPAGE �IT -"" OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC 'WELL PUBLIC DOMEST-PC WELL ' <br /> INTENDED USE v�TYPE OF WELL',,_) CONSTRUCTION SPECIFICATIO S <br /> Industrial ', iia 'fie Tool Dial of Well Excavation t <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public V Driven-- Gauge of Casing <br /> Irrigation _1 Gravel- Pack Depth -of Grout Seal ' t <br /> Cathodic ,protection Rotary Type 'of Grout <br /> Disposal r' Other , Other fiiformation <br /> —Geophysical .� � ! <br /> Surface 5ea1 I�is��al_1ed I3y�: <br /> � I <br /> PUMP INSTALLATION. Contractor - <br /> „ TYPe of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: .x'•./_-/----State-Work--Done"°'°®"" <br /> bL/) o/�. q �7afid <br /> DESTRUCTION OF WELLp:: _Wel DiamW e. er PR-0�� Pay -7 Approximate Depth <br /> I}e`scrib`e'-IJl�tet'�al"`arid'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 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D FINAL INSP ON. <br /> SIGNED TITLE (� <br /> (DRAW PLO PLAN ON VERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I -" <br /> APPLICATION ACCEPTED BY DATE 3 11-7 <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHAS GROU7 INSPECTION f PHASE /FIN INSPECTION <br /> INSPECTION BY DATE _7_ INSPECTION BY DATE <br /> dN.. I' FT c vmn�.�tT <br /> . 6/77 . 2r�11191;11191; J <br /> F. H 79no., r_�i <br />