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Caa Nit lam'�r��.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL;OFFICE SE:. ff'"'�F�1601 E. Hazelton Ave. , Stockton, Calif. <br /> V ; Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &__ ZZo <br /> y THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8..17-7 <br /> (Complete In Triplicate) W <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 /> i <br /> JOB ADDRESS/LOCATIONo y! ���� �- �.,'�-r �Q <br /> cENsus TRACT <br /> .Owner's. Name . 'ar, ccs, <br /> ` rrt J Phone ' <br /> Address S a S' �-:'fes �.,L". City <br /> Contractor's Name � �/ License # !. ,w Phone qej�7-X261, -. <br /> I <br /> TYPE OF WORK (Check)-. NEW WELL -/7 DEEP_EN.-/7: *RECONDITION / f <br /> 7 DESTRUCTION / <br /> PUMP INSTALLATION / l PUMP REPAIR'/x-7 PUMP REPLACEMENT /? <br /> Other Z_1 , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY X. <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 �4 <br /> Industrial Cable Tool Dia, of Well Excavation} <br /> Domestic/private Drilled Dia. of Well Casings ' o4 <br /> Domestic/p.ublic. Driven Gauge of Casing f: jI <br /> Irrigation Gravel Pack- Depth- of Grout Seal ' l� <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ' � <br /> . <br /> -Geophysical '- -- - <br /> . � . Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type .of Pump ,�' &i U <br /> PUMP REPLACEMENT: / / State Work Done :. <br /> PUMP .REPAIR: -.. /X% State Work oneA <br /> �a,� �� . ,h ! �� !�d�►� dv/ `'' � /" /J�-d��- SLS d-J t. ..- �•�i - __ .._ ., <br /> DES;TRUCTION OF LL: Well Diameter Approximate Depth <br /> Describe Material and 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 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-bestof m knowledge_and bel df, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D A FINALINSP �T , <br /> TITLE �"`r41 <br /> aD PLOT PLAN ON RVERSE SIDE ` <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> . <br /> t .. <br /> APPLICATION ACCEPTED BY' ' DATE ' <br /> ADDITIONAL COMMENTS k <br /> PHASE II GROUT INSPECTION ' PHASE III FINAL INSPECTION <br /> i4 INSPECTION BY .t/ DATE INSPECTION BY f� DATE <br /> E H 1426 . Rev: "1..74 r s h/75 2M <br />