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s ' SAN JOAQUIN LOCAL HEALTH DISTRICT f! /-7-7 £ � <br /> FwOOFFICE USE; 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone : (209) 466-6781 <br /> PLICATIONFOR OR WELL CONSTRUCTION OR PUMP ,PERMIT Permit No. -77-I3zZ� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 g �`2r- ,. CENSUS TRACT <br /> Owner's Name 1es lr--e vaega Phone <br /> i. Address City <br /> Contractor.',s. Name /�, _ //,m ..-Cc, '`: ° -License .Phone...P 7-_Y?';2=51'_ . <br /> i <br />` TYPE OF WORK (Check)-: NEW•WELI: DEEPEN / / RECONDITION'-'/-----7/-- - DESTRUCTION - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 f <br /> 0ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Ira' PIT PRIVY ­e9- <br /> SEWAGEDISPOSAL FIELD%rig. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINED PRIVATE DOMESTIC WELL llor PUBLIC DOMESTIC: WELL - p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial { Cable—Tool Dia, of Well Excavation a.r FF <br /> Domestic/private Dri-lledj, <br /> { Dia.- of Well-•Casin•g- <br /> Domestic/public Driven ' -- <br /> Gauge of Casing ,leo PS/ Pdc, <br /> Irrigation l X Gravel Pack Depth of Grout SealSg r <br /> Cathodic Protection -Rotary-- Type of Grout <br /> . ' ce- o aT <br /> Disposal Orhe.r Other Information <br /> Geophysical Surface Seal Installed By:(/e//t y A6_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump « H.P. <br /> IPUMP REPLACEMENT: <br /> State Work .Bone <br /> PUMP REPAIR: <br /> / / State Work ane <br /> IDES TRUCTION OF WEL� : Well Diametdi" . fig► iT6�- w Approximate Deptho <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 of the 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 TO GROUTING ANDA FINAL )j4SPECT ION. <br /> SIGNED TITLE �. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> I FOR DEPARTMENT USE ONLY <br /> I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E JIII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/ <br /> II C ^�jy. <br /> E H 1426 Rev. . 1-74 f �i ��f iif77 2M + <br />