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€ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. o 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-3Q-7„, <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Districtm <br /> for a perit 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 /> 11 <br /> k JOB ADDRESS/LOCATION 710 F) S7(mt <br /> CENSUS TRACT <br /> Owner's Name RnLo Phone <br /> Address »'r Lc City t S C J-ko-✓ <br /> F Contractor's Name I��I 5✓W0� g0� License # ,:��901� Phone ' &J-a22% <br /> I I� <br /> 4 TYPE OF WORK (Check) : NEW WELL / / DEEPEN I I RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /f <br /> .Other <br /> DISTANCE TO NEAREST- - 'SEPTIC TANK �SEWER-LINES- 7----PIT-PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> `,'Indus�tfial Cable Tool Dia.: of Well Excavation <br /> Domestic/private Drilled Dia.3of Well Casing \ <br /> Domestic/public ) Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary Type- of Grout <br /> 4 Disposal �� Other Other Information <br /> Geophysical Surface ..Seal-Installed. By: <br /> PUMP INSTALLATION: Contractor <br /> i I Type of Pump H.P. <br /> ' PUMP REPLACEMENT: / State Work Done !�F � v- 7u-_S.CL <br /> � � rte. J. --. - -- <br /> � s <br /> PUMP .REPAIR: / / State Work Done <br /> ° Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter PP P <br /> Describe Material and Procedure <br /> iI 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 Distract a <br /> WELL DRILLERS REPORT of-the-we II.and-notify-them.-before<.putti-ng--the wel1-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 GJQUING (NN 11A FINAL INSPECTION. <br /> SIGNED TITLE <br /> M6 <br /> DRAW 'PL T PLAN ON RE ERSE SIDE <br /> M I <br /> i t FOR DEPARTMENT USE ONLY <br /> PHASE I a <br /> .- ,, DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: II <br /> PHASE II, GROUT INSPECTION PHA$E II/FOAL INSPECTI / <br /> DATE INSPECTION BY / // DATE /�A� <br /> TI <br /> INSPECON BY ` <br /> � 3/76 2M <br /> E H 1426 Rev. IT74 -- <br />