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- - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: '' 1601 E. Hazelton Ave. = Stockton, Calif. <br /> Telephone:`- °-=(209)''''466=6781 f <br /> 'APPLICATION FOR WELL. CON§iRUCTI-ONAR PUMP PERMIT Permit No. 7 <br /> 76-1,913 P <br /> THIS 1?ERMI-' EXPYRES- �. 'YEAR FROM I DATE�18SUED' Date Issued /a- 7 <br /> .(Compl'Ete JIn Trip'1ica'te) r= <br /> Application`is`hereby'made�to',the• San. Joaquin- •LoZll -He'alth Dls.triict'.for a permit to constr-u'c�t� <br /> and/or install the work herein described. This application° is. madie'in.compliance with -San Joaquin <br /> County='Ordinax ce'No: 1862•ian`d -'the Rt`i1es; ind'`R gulations'-bi,�`the• Sail Joaquin, Local°Health °District " <br /> JOB ADDRESS/LOCATION r3 141SL�e- T/O CENSUS"TRACT <br /> Owner"Si 'Name It Phone 4o" y7 <br /> Address � �7 e-Af ZI(/ _. ..». - - City T <br /> Contractor's Name /t}f{ I;icese: �� aj Phone $Si>-:a3 p1l <br /> TYPE OF WORK (Check) .- NEW WELL DEEPEN' / ./ RECONDITION7/�/ ` DESTRUCTION /_7 <br /> ' P, : INSTALLATIONS:f PUMP REPAIR' -/ kimP REPLACEMENT /_7 <br /> r i Other <br /> AVX <br /> DI$fiANCE TO NEAREST:. SEPTIC TANK Zljp ` SEWER LINES. PIT•'PRI <br /> JF <br /> . y SEWAGE -DISPOSAL -FIELD , ,CESSPOOL/SEEPAGE-•PIT OTHER <br /> PROPER Y. LINE 4 PRIVATE DOMESTIC WELL PUBLIC: DOMESTIC WELL <br /> IMNDEV,USE TYPE OF-WELL `CONSTRUCTION SPECIFICATIONS (,U•. <br /> Industrial : Cable Tool- 'bia...'of'.Well Excavation `Q <br /> _ <br /> Domestic/private Drilled Dia. of;Well Casing <br /> — -- <br /> Domestic/public .. Driven Gauge of Casing <br /> Z <br /> Irrigation �,- :-Grvel .Pack.. Depth hof..-Gout Seal �O <br /> . - <br />` Cathodic Protection iA Rotary T:y e' of. Grout <br /> Disposal 'Other 'Other 'I iformatiofi w <br /> Geophysical Surface Seal Installed By;__ _ <br /> PUMP INSTALLATION. Contractor <br /> a <br /> _.,�....w...A.T.ype_of_pump_ <br /> PUMP- REPLACEMENT: / / State Work Done " : • `' <br /> PUMP .REPAIR: / / State Work Done r <br /> AES-TRUCTIONEOF-WELL: Well Diameter*..' f �` --.Approximate..Depth <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. n.otify them before putting the .well .in. use.. The above . <br />'L 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 r TITLE A, y <br /> W. PM PLAN ON RE RSE SID93 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION..ACCEPTED. BY DATE D /6q <br /> 7G <br /> ADDITIONAL COMMENTS: <br /> PHASE II PROUT INSPECTION PHASE III/FINAL -INSPECTION <br /> INSPECTION BY ; DATE / •/ INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 376: 2M .- <br />