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SAN JOAQUIN LOCAL:HEALTH DISTRICT <br /> ,IOR!OFFICE USE: 1601 E. Hazelton,AVe: Stockton Calif. <br />` Telephone ff".(204) _466`=6781 <br />! APPLICATION FOR WILL CONSTRUCTION OR `PUMP PERMIT Permit No. ;ry _T 7r <br /> Irk <br /> THIS,ePERMIT`EXPIRES. 1k YEAR,FRCPI,DATE' ISSUED ­ ,',Date i.Issued <br /> rA <br /> (Compkete In 1:eip1icate) <br /> Application is hereby made to the San .Joaquin Lgca1Health Dist ict..lox'.a.permit4,toi-construct <br /> and/or install .the work herein described. ,. Th 4a0pkicatioii ie ''itt de-in-.compliance with' San Joaquin <br /> County-Ordinance. No. 1862.. and the Rules and` Ae: ulatiods of-`,the .San,Joaquin Local ,Health District. <br /> Lo <br /> ,SOB ADDRISS/LOCATIONq., � Uri '�QR4 ?? .f�... _ -1 , CENSUS` TRACT <br /> E Owner°s Name ,; w Phone._ S!t ✓: S!a <br /> Address ��:.. . . �.- �L.,.,._ — �... Cit . <br /> 8 ,.� <br /> Contractor's .Name..... License .# ./20 y-Phone ��7N-7e) <br /> TYPE OF WORK (Check): NEW WELL 4-7 DEEPEN /_7 RECONDITiON /? DESTRUCTION- ' ' <br /> PUMP INSTALLATION. / j PUMP REPAIR /_ PUMP 'REPLACEMENT <br /> L, Other / / <br />{` -DISTANCE TO-NEAREST: SEPTIC TANK ISEWER LINES PIT PRIVY �� } <br /> • ti SEWAGE, DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER A ` <br /> sfs,�Aq <br /> PROPERTY LINE - PRIVATE DOMESTIC WEI:L'' "'`" PUBLIC DOMESTIC WELL <br /> 4INTENDED USE f TYPE OF WELL CONSTRUCTION- SPECIFICATIONS.: <br /> Industrial j�( Cable ToolDa. .of Well .Excavation <br /> i <br /> ,Domestic/private Drilled Dia.-of•Well Casing <br /> 4 Domestic/public Y1 ` Driven' Gaaga of Casidg 9a�c..• :. �4,a =. <br /> Irrigation k� Graver Pack Depth of Grout Seal <br /> --Cathodic. Protection Rotary 74---, 6—Type--of t. Grout <br /> "Di'spos$1"" . OEher Uther Information <br /> Geophysical h`w Surfice.Eeal Instalked.B : <br /> 4 V <br /> PUMP INSTALLATION: Contractor '_ <br /> f Type of Pump J J H.P. <br /> PUMP REPLACEMENT: %/ State Work Done 1 V <br /> PLM -!REPAIR: /7 State Work Done. <br /> OtA <br /> , ESiRUCTION OF WELL: Well Diameter f Approximate Depth 1 . <br /> Describe Material and Procedure : ! <br /> I herebyagree to comply with all laws and regulations of .the. San.:Joaquin Local Health District <br /> and: the State-of-California- pertaining -to;-or,regulati.ng el+l construction: "-Within•FIFTEEN DAYS <br /> `!'after completion of my work.on.a new,well;I_wil'1_furnish.the ..San.J.oaquinwLocal.Health-District a <br /> WELL�_DRILLERS REPORT of the well and notify them before putting- the- well in use... The above <br /> ormation,is true to the best-of: my:knowledge and belief.. I WILE' CALL 'OR"A GROUT INSPECTION <br /> 'PRIOR-TO GROUTING A WA-'FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE 'SIDE <br /> tTMENT USE ONLY t <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY ' r <br /> DATE �] - Z ZT 7 y I <br /> ADDITIONAL COMMENTS; � �+ ,. <br /> . PHASE II GROUT INSPECTION PHASE III/FINAL-INSPECTION ✓c?� <br /> INSPECTION. BY_ DATE { INSPECTION BY DATE <br /> H,1426 Rev. Iw74 * Ael : 1-74.. 2M <br />