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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. aL_2_1q4-Ae9 <br /> TIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o_ <br /> if Q ;( SV• `a�uTr�✓ ,2 .sa (Complete in Triplicate) �S --.LZ� <br /> Application is hereby made do 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 Na. 1$62 and he Rules and Regulations of the SaoJoaqu n Local Health District. <br /> �nf�.�r�c E��a,� •x'�i E � -w Cry��r f...,�c- � �v s �i� <br /> JOB ADDRESS/LOCATION 4 w'0 e, e.v +C�. ga. c S c�� Av5 4 aa�.� f- jg CENSUS TRACT <br /> S;O. <br /> Owner's Name ' ' <br /> Phone S `�•-�? <br /> Address17 M-1. <br /> :,� Gi ty <br /> Contractor's Name License Phone - p <br /> TYPE OF WORK (Check):' NEWWELLI/7 DEEPEN/? RECONDITION /7 DESTRUCTION f7 <br /> t PUMP INSTALLATION PUMP REPAIR /_7 PUMP REPLACEMENT 17 <br /> } t Otherl./ / <br /> DISTANCE TO NEAREST: 1SEPTIC TANK SEWER LINES ; , PIT PRIVY <br /> SEWAGkDISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WkL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private -' I Drilled Dist. of Well Casing <br /> Domestic/public. y ;: .Dfivent Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -1—Rot-ary Ty—gee -of Grout <br /> Disposal Other Other Information <br /> _Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> type <br /> mP REPLACEMENT H.P. <br /> PU . <br /> MP r A. <br /> / / State Work Dane n,. 7 <br /> 'REPAIRi �.�..I I State Work Done """' '"'""`. ; . _ r <br /> Y <br /> ES:TRUCTION OF WELL: Well Diameter j <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply withiall 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 ori 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 FO 'A 'GROUT INSPECTION <br /> PRIOR TO GROU ING AND A, FINAL,-INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAREVERSE SIDE <br /> PHASE I <br /> F N ON OR DE MENT USE ONLY, <br /> . <br /> Al'P�A ION ACCEP <br /> ADDITIONAL COMMENTS: j DATE - -E <br /> PHASE. I GROUT INSPECTION P II NAL INSPECTIO <br /> INSPECTION SY DATE INSPEC DATE u. <br /> E H 1426 Rev. 1-74 <br /> 7_7A Its <br />