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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK OFFICE USE: i 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r 3064) <br /> i <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 7_,'7423- <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 , Y,_ LN,R _rj?,2 , CENSUS TRACT <br /> Owner's Name " A. Phone <br /> f , <br /> Address ~( :. city <br /> Contractor's Name <br /> 1�✓� .U��L t '_ .1.I 7 - License �L G Cz. Phone Z-,1'6777 <br />` TYPE OF WORK (Check): NEW WELL / DEEPEN '/7 RECONDITI'ON' /? 'DESTRUCTION <br />€ PUMP INST LATION / / PUMP REPAIR /� PUMP REPLACEMENT /7 f , <br /> Other <br /> �! <br />� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> E <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -P..UBLIC DOMESTIC WELL 06 <br /> INTENDED USE 11 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �1- ' X Cable Tool Dia. of Well Excavation <br /> Domestic/private II Drilled Dia. of Well_-Casing <br /> Domestic/public �) Driven Gauge of Casing r <br /> Irrigatioi Gravel. Pack Depth of Grout' Seal, <br /> Cathodic Protection Rotary Type of Grout; <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By. )377 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> F <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 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 ofllthe 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 T9-t_R_0TIW AN A '`FIN r INSPECTION.- <br /> SIGNE li TITLE c <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />' PRASE I E FOR DEPARTMENT USE ONLY y - <br /> APPLICATION ACCEPTED BY c• <br /> ....... <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE 111 FNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -z -�� <br />' <br /> _2M.. <br /> E H 1426 Rev. 1-74 L/75 ....._ _._ <br />