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SAN JOAQUIN. LOCAL'HEALTH DISTRICT <br /> FO�fOFFZCF. USE: 1601. E. • Hazel tonrAve.', Stockton, Calif. <br /> Telephone: - (209) 466.16781. <br /> APPLICATION FOR WELL'CONSTk1 CTION OR PUMP PERMIT Permixyt.{No <br /> . ., :a%..� e.+yr.y sy, s�l!,,: 4S_.;�� f 4 .J,, ...^.� 1. °' %. •f� # ` . ,. S'I"`„-.. .'ia' <br /> THIS°,PERMIT sEVIRES I=Y FROM;,PATE*',ISSUED 4Daze.-,.Issued -7:�- <br /> . _ ct <br /> (Complete+: in Triplicate) ' � r :r or 7. <br /> is 'hereby made to the Sap,Joagnn:._ ,oeg1 }health ?iatricir £or • , permit to canstu <br /> Application <br /> an4/4r: instalL.thet.work_herein described. -_-This%appluicatian,.,,,is, made :fn--compliancd with.,San;Joaquin <br /> c - ,.Rgulzkt�lon6,•.%of..,the;San i Joaquin Local Health District,Coznty.a dinance do.X1862..-end the_Ruiea and <br /> & ,CENSUS TRAG-1 <br /> JOB ADDRESS./LOCATION , . <br /> �' r <br /> V N.:1•f, tl+Y� r;4 ...c'.-� . . . - E .i t .. q�y�. <br /> one <br /> Owner's Name Y ` <br /> Clay <br /> Contractor's Name 1. > License. ;.1. Phone Kik y�7� <br /> TYPE f OF WORK (Check):•. .NEW WELL 1-47DEEPEN 17 RECONDITION /77-.-DESTRUCTION / T <br /> PUMP.INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT_47.` <br /> Other•,L7 , <br /> DISTANCE TO NEAREST: ' SEPTIC TANK 4 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL.FIELVCESSPOOL/SEEPAGE PIT OTHER ` <br /> PROPERTY LINE -» PRIVATE-DOMESTIC-WELL! . 'PUBLIC -DOMESTIC WELL <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> 'Industrial :_ k Cable Tool Dia. of Well Excavation <br /> Domestic/private.', Drilled Dia. of Weil Casing <br /> Domestic/public Driven Gaugewof Casing <br /> `Irrigation GraYelPack Depth of Grout Seal <br /> - <br /> .Cathodi-c-Protectl-ons- --•-- Rotary.--�•�-....—.�Typelof-.Grout <br /> Disposal k Other Other; Information: <br /> Geophysical Surface Seal Installed BY: _ - <br /> yPUMP INSTALLATION: Contractor <br /> Type Of,Pui t1% I H.P. <br /> � _ ., ,,, , .. ... .. ; Jf, ,., -• .... . ..� A . -. ._ ... �� <br /> PUMP REPLACEMENT: /_ .State 19ork Done <br /> PUMP .REPAXR:r L7 -State-Work Done>>•Y �+ _,�� '.=- <br /> /IV t■�, <br /> ESTRUCTION OF WELL_:` Well Diameter:_ e • 't �'�- APproxiutate Depth` <br /> Describe Materialand Procedure%# <br /> I hereby agree to comply with all laws and re'gulatiogs'of the San Joaquin Local Health District <br /> and the State, of �California-pertaining to or 4`egulating •well construction. Wi:thin• FIFTEEN. DAYS <br /> ' after completion of ray work bn a new well, I will..:furnish the .San Joaquin Local Health -District � <br /> Er <br /> WELL DRILLERS REPORT of the well and notify them before putting..the well.: in.use.. The above <br /> information 4s- true to the •best-•of� mq .knowl�e�dRe dib;eiief:' I WILL CALL'FaR A'GR(}UT` INSPE TION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTION . <br /> SIGNED } g rr; .. ... TITLE ` <br /> ... .(DRAW PLOT PIAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE:ONLX I <br /> PHASE Iy'- ` _ f _ 2• f <br /> APPLICATION ACCEPTED-BY <br /> �. ADDITIONAL COMMENTS,:X 01- <br /> r <br /> PHASE IIGROUT INSPECTION `”' PHASE II INAL INSPECTION 1 <br /> INSPECTION'BY `. DATE ........ . . . <br /> INSPECTION BX DATE Ta /3 76 <br /> FEi 'tJE H 1426 � J Rev. •„1-74�1� "•' `' 1-74 2M <br />