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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOlkF-ICE' USE' 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> �� APPLICAT,ZON FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 G 55 <br /> THIS PERMIT+EXPIRES 1 YEAR FROMDATE ISSUED q <br /> ' Date Issued �7 <br /> I (Complete :In Triplicate) <br /> ApPli� ation 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 /> ` <br /> County Ordinance No. 1862�and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION..Z1_3 of <br /> CENSUS TRACT <br /> Owner's Name `� f <br /> f Phone s' <br />=Ad'dre E s <br /> cityV. <br /> [ <br /> Contractor's Name ,�!� p� �` _ --- <br /> �� Licen)j?,F.Z(, 72> Phony V15- <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN RE t <br /> I CONDITION /_/ DESTRUCTION /� ; <br /> PUMP INSTALLATION �PUMP RE IR / / PUMP REPLACEMENT /7 <br /> Other /� / . <br /> � 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK23 8 <br /> E W <br /> SEWER LINES v PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ <br /> PROPERTY LINE - PRIVATE DOMESTLC-WELL PUBLIC DOMESTIC INTENDEUSE D TYPE OF WEL- <br /> Ipndustrial =' `r ' CONSTRUCTION SPECIFIICATIONS �- <br /> �cDomestic - _`Cabl al <br /> Dia.,sof Well Excavation <br /> Domestic/Private R xi7�led Dia.tbf Well Casing <br /> /public given Gauge of Casing <br /> Irrigation- gave] Pack Depth"of Grout etCahodic Protection I' Ltary yp4e�f ;� �•. <br /> — <br /> Grout <br /> i,.sposal Other Other Infoirmation <br /> Geophysical -- <br /> Surface Seal Installed B <br />'UMP INSTALLATION: *ct <br /> Contr.actar -017, - <br /> Type.7of Pump <br /> UMP REPLACEMENT: / %I .State Work Done �. <br /> UMP----.REPAIR: %tate Work Done <br /> ISiRUCTION OF WELL: Well Diameter ; <br /> Describe Material and Procedure Approximate Depth ' <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Id the I[State of California pertaining to or regulating well construction. Within FIFTEEN DAYS_ <br /> Eter completion of my work on a new well, I will furnish the San Joaquin Local Health District- -a <br /> ILL DRILLERS REPORT of the well and notify;them befo� re Putting the. well in use.. The above <br /> iformation :Lg'tru-e to t"he es o my knowledge and belief:`-i WILL CALL "FOR. A GROUT INSPECTION- <br /> IOR TO', GROUTI ,k AND A FINAIINSPECTION. <br />.GNED <br /> �_�. ; .� •�..,- TITLE <br /> ' .(DRAW <br /> .,PLOT PLAN ON*REVERSE SIDE) <br /> EASE I <br /> FOR DEPARTMENT USE ONLY !` <br />'PLICATION ACCEPTED BY <br /> DITIONAL COMMENTS: DATE <br /> PHASE II GROUT:, INSPECTION <br /> SPECTION BY 41 PHAS II FINAL INSPECTION <br /> DATE INSPECTION BY'-/ DATE • a �' " <br /> E H 1426 _Rev. 1-74 _ it 1777 <br />