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W r P -71///7,;7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB4OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> <; Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�4 jA) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &-,ay-2 <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 Rulg 7d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Z tJ/<--O ,/c�/E/S/�7r� 9a�6 3_r <br /> Phone <br /> Address City <br /> Contractor's Name _� �iyr License `' 3;�3 <br /> TYPE OF WORK (Check): NEW WELL/DEEPEN /-' RECONDITION /-7 DESTRUCTION <br /> PUMP INST ON / / PUMP REPAIR /-J PLIC$ <br /> Other , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 77—, 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 SPECIFICATXONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ✓Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing lpu <br /> Irrigation Gravel Pack Depth of Grout Seal 340 IV <br /> Cathodic Protection vo' RotaryType of Grout -ryf <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: x_ <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; /� State Work Donk'�2�' <br /> PUMP 'REPAIR: <br /> /-7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter / <br /> o � Approximate Depth -� <br /> Describe Material and Procedure s <br /> "14-11t <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 a <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 AND A FINAL INSPECTION. <br /> SIGNED TITLE _ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I F� <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTgV BY DATE *,_� <br /> ADDITIONAL CO <br /> I N ECTION PHASE II F AL INSPE I <br /> INSPECT DATE 12s �tNSPECTION BY <br /> a� DATE <br /> /�Y/�?"i--r4 — 10 /y/fir-' Svc S.'a'..,r- -AW ..,�.� ..., ec�r�ue�c� <br /> ,,, F .Pc rw t �o•�s( myna/` ,o<ua ,� t . T_Z�7g <br /> Rev. 1-74 r--. <br /> E H 1426 9ot ooc- Nof 1416.0 <br />