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SAN JOAQUIN LOCAL +HEALTH DISTRICT <br /> FOE 0FFICE-USE, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> J APPLICATION FOR WELL—CONSTRUCTION OR PUMP PERMIT Permit No. Ifo_ S3 Jv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> =� I (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 �] /j L �� CENSUS TRACT - <br /> k Owner's. Name S_e_.._ e-Z-7 41 I/ Phone <br /> k TS�� <br /> AddressLf�LLs'13,11 ._ City <br /> Contractor's Name r q� License # 6 Z)) Phone I� <br /> .... .�,,.��'�+;�..-_r—,.�—"•�__-••°-4�-=---_•-`� __�..���y,,,.._ _�..ti.�.t-+ »�, _.,�,�_ _�- --•,.cam,-t`.'�"-��"Yfi� <br /> TYPE OF WORK. (Check) . NEW WELL / / _._DEEPEN %/ RECONDITIONS/ DESTRUCTION / <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other . / / <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY, <br /> w.� x <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 Cable Tool Dia, of Well Excavation <br /> " A! _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing � f <br /> Grout <br /> of De th� <br /> Irrigation Gravel Pack �g p Seal <br /> r' _ .Cathodic Protection Rotary Type of Grout [ , <br /> A Disposal Other Other Information � <br /> Geophysical Surface Seal Installed By: ; <br /> f> - - ; <br /> PUMP INSTALLATION: Caritractor <br /> Type of Pump 4&2,77 4omA, eo& H.P. _ 6 <br /> PUMP REPLACEMENT: / / State Work Done /{� L,26 <br /> PUMP.REPAIR:_ /�/,.�5.ta:te-Work.FDone. . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L y <br /> f, ily-'nereby 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 co eti of my work on a new well, I will furnish the San Joaquin Local Health District a-- <br /> JELL DR LERS RE RT of thew l an tify them before putting the -well in use. The above <br /> inform tion is t u to he s o know I WILL CALL FOR A GROUT INSPECTIO I <br /> IOR O GR UT G AND FI CTIO <br /> =NE TITLE <br /> DRAW XPi, T' PLAN ON REVFRSE SIDE) <br /> I FOR DEPARTMENT USE ONLY � <br /> 7CATION ACCEPTED BY DATE <br /> TONAL COMMENTS: • - _ I __ 1 <br /> i <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON., <br /> CION,. BY DATE INSPECTION BY DATE b�1426' Rev. 1- 74 3 76 2M � <br /> � _ � . <br />