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SAN JOAQUIN LOCAs. 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) /77-- 05o--03 <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 Sarn�Joaquin Local Health District,. <br /> r <br /> .iJ�.,�(l�t? �7', ire! c^�•" F!�?.�N�N CJS M/� ���� .Pa�chlc '/�. �Z , <br /> JOB ADDRESS/LOCATIO 7P,7* 1-115 T /�e"t2 ,: CENSUS TRACT <br /> Owner's' Name ('6 f #Y1 Taff Phone <br /> �G <br /> Address I7 City tfz)/,)P <br /> Contractor's Name License #7�GOZ Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION FT. 'DESTRUCTION /_7 <br /> PUMP INSTALLATION / / Pi1MP REPAIR % / PUMP REPLACEMENT /_7 <br /> Other <br /> � f r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial : X_ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing A5, <br /> _ <br /> Domestic/public Driven Gauge of Casing . 2 <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 <br /> :PUMP INSTALLATION: Contractor <br /> Type 'of Pump H.P. l <br /> it <br /> PUMP REPLACEMENT: / / ;State Work Done <br /> PUMP .REPAIR: / / State Work ,Dane <br /> DESTRUCTION OF WELL: Well Diameter �.:�; " ` Approximate Depth k1 <br /> Describe Material and Procedure k <br /> GI 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;weIl '-constructiion. _wWithin FIFTEEN DAYS <br /> " after completion of my work on a new well, I will furnish the San Joaquin Local 'Health. D'istrict a <br /> WELL DRILLERS REPORT of the well and notify them beforeputting 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 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> (APPLICATION ACCEPTED BY ^ _DATEY-/2 /G"7? <br /> �ADDITIONAL COMMENTS-: Y l ^ a <br /> PHASE II GROUT INSPECTION _rr ' PHASE III/FINAL INSPECTION _f <br /> VINSPECTION BY DATE INSPECTION`BY DATE r"'7�J <br /> r1177 _ 2M <br /> �' R H 7426 RPv_ 1-74 _ <br />