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t <br /> 4SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI70FFICE USE. /11601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/_2-7,K <br /> } v... t (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 hereln described.,. This application,is made in compliance with San Joaquin <br /> County Ordinance No.41862•and the Rules and Regulations-of the San Joaquin Local Health District. <br /> r. JOB ADDRESS/LOCATION 74.,3 -- ,AEg - n/ CENSUS TRACT <br /> } 5 <br /> Owner's Name , � � �. _�Al � Phone <br /> Address �. . ._ _ _. City S7A 31 <br /> # # OR nox <br /> Contractor's Name t A 14'a-el S. C10 License # 5 977 Phone 5r3 <br /> TYPE OF WOR&•-(Check'):�°'�'NEW-WELL/��EEPEN / RECONDITION / DESTRUCTION '/ - ."' <br /> PUMP INSTALLATION / / PUMP REPAIiiki . PUMP REPLACEMENT <br /> a Other / T ?:- y, <br /> DISTANCE,TO NEAREST: SEPTIC TANK _j-4 -.t $EWER LINES 7 PIT PRIVY <br /> Illr SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I F s <br /> PROPERTY LINE -- 'PRIVM DOMESTIC WELL` S PUBLIC DOMESTIC WELL <br /> `INTENDED USEi TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> jhdustrial _ Cable Tool Dia of :Well Excavation " r <br /> /D � <br /> \ <br /> mastic/private . Drilled Dia. ofy :Well Casing N <br /> r ;Domestic/public' Driven Gaugewof Casing IVAI <br /> Irtigation aM j-, Grravel Pack Depth of Grout Seal _1~6 <br /> -Cathodic Protection L—Utary Type of Grout - j Z& M1VZ <br /> 'Disposal Other Other Iuf oruation <br /> = Geophysical t Surface Seal Installed By; _J7 14.E <br /> i � > , � .,.�...s�,.4. ,:� -. }_ �.,..-ate,� �: ..,�.....--�.-..- •-,..r�� <br /> E '.PUMP INSTALLATION: Contractor A; ..• <br /> Types of Pump H.P.PUMP REPLACEMENT: // State Work Done <br /> .PUMA .REPAIR: /? State Work Done e , <br /> j1ES;TRUCTION OF WELL: We.11 Diameter Approximate Depth Jr <br /> Describe Material and Procedure: 1,41,rf2 io r <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 wi11%furnish the San Joaquin Local Health District A <br /> WELL DRILLERS REPORT of the well and notify them before- putiing..the. well in.use.. The above <br /> information is true to the-best of my-knowledgi.,�and belief, " I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION; � <br /> SIGNED, :TITLE i LJoe <br /> DRAW PLOT PLAN ON REVERSE .SIDE <br /> !� <br /> "' FOR.DEPARTMENT USE ONLY <br /> PHASE.I <br /> ,'APP CATION ACCEPTED BY ray.� I f I DATE ' ' /2 7.f i <br /> ADDITIONAL COMMENTS: gd�g&j IQIA�—�f_ <br /> PHASE Tj 1 QB47INSPECTI '" PHA I;EIIMAL INSPECTION <br /> INSPECTION 13f DATE i INSPECTION BY . -� DATE /.� IE <br /> [ - , <br /> E ;H 1426 . Rev. 1-7 4 1-74 2M <br />