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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 <br /> OFFICE USE`: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z2-62Z,4,) <br /> r 77 T <br /> - THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A,2f--Z, <br /> I'F (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 /> i=: County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> II CENSUS TRACT <br />} JOB ADDRESS/LOCATION <br /> l Owner's Name E Ph-one IF03 <br /> ELIL— <br /> dctress �L'd'a City /M6�NT <br /> Contractor's Name. - AOE�AC, <br /> Lic1.ense # Q Phoneq f�'-rn7 <br /> .TYPE OF WORK;(Check) : NEW WELL / T DEEPEN /. I,_ RECONDITION /-7 DESTRUCTION I�T <br /> ( PUMP INSTALLATION-0 PUMP REPAIR %`/ PUMP-REPLACEMENT 17 <br /> f ,......_... ' Other <br /> DISTANCE TO,NEARE'ST: ' SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL `r <br /> INTENDED USE °- kTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial } Cable Tool ;`, Dia,, of We11 Excavation <br /> G <br /> Domestic/private :, p Drilled Dia. of Well Casing, r <br /> A,j2 10, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation t Gravel : 19 <br /> Pack Depth of Grout Seal _ u' f - <br /> ., _ Cathodic'Protecti6ii ^,Rotary �, Type of GroutT �} <br /> X, Other Inf ori <br /> maton ' 4 y <br /> _ - - Disposal � �Ottier �-.--- -� <br /> Geophysical. C/ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' H.P. <br /> Type of PumpH.F. <br /> PUMP REPLACEMENT: . / '/-k <State Work Done <br /> PUMP .REPAIR: . / / State Work Done <br /> DESTRUCTION OF WELL: Weil Diameter Approximate DepCli,� - <br /> Describe Material and Procedure <br /> b <br /> I hereby agree tot`comply with. all._.laws=and:_regulationsr,of__the^San;Joaquin Local Health District <br /> and the State oCalifornia pertaining to or regulating well construc`tiori.- Within 'FIFTEEN DAYS <br /> f <br /> after completion of my work on a new well,-I wil1 'furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT.-of-the.well.-and-notify_,them-before-putting .the-wgu—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 GRO TNG AND A NAL INSPECTION. <br /> SIGNED TITLE <br /> p D W PL, T FLAN ON RE SE SIDE F <br /> FOR DEPARTMENT USE ONLY <br /> f APPLICATION ACCEPTED BY 7 ul�f DATE <br /> ADDITIONAL COMMENTS: I� III/FI AL INSPECTION <br /> PHAS I GR T INSPECTION ATE <br /> INSPECTION BY ! DATE - �� _ INSPECTION BY <br /> (076 2M <br /> E H 1426 Rev. 1-74 - - <br />