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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. 7S:; P2 9/ya <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r--,7-u-, S- <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I,. ,,T ra S',/I c A F-("S 1 0 o-.'H ice'b F.g L 7- 1-3c e_ <br /> _moCENSUS TRACT <br /> Owner's Name 3 ,;z 2 Y R,o cc-is Phone 3( - `!3 6:", <br /> Address `i�5�> [ -�, ���,;h-'o�� �_ ( �� City L_(-) 01 <br /> San Joaquin Pump o. <br /> Contractor's Name (Division of San Joaquin Sulphur CO.) License # Phone <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION f7 C <br /> PUMP INSTALLATION / / PUMP REPAIR/? PUNP REPLACEMENT 21V .�` <br /> Other f-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PIOPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC, MSTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: State Work Done �, ! -, 11 f' P(lit, <br /> T" L1-t,.��4��E' � N I� /u lcc��.c�� Cc I, l� Scc� -a <br /> PUMPIREPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Q <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 <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 INSP CTION. So., h000(:in Pump leo <br /> SIGNED rc - TITLE Myislan cf Son J <br /> DRAW PLOT PLAN ON REVERSE SIDE 5001 E. KettigmCp ` <br /> FOR DEPARTMENT USE ONLY ovi, alifornin <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 14 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 <br />