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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FpF�.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , 9-I�� <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED Date Issued <br /> � z <br /> j y e (Complete In Triplicate) <br /> Application is hereby made to thSan 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 Qrdinance-No.,1862-..and:-the,,Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ! U <br /> 'CENSUS TRACT <br /> Owner's Name <br /> r� C Phone <br /> Address Q, o ��` <br /> z 617 City -�U, CL-`�/O y <br /> Contractor's Name ry ems. f License �� �j�� phone 6?2 <br /> f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /= / RECONDITION /—/ DESTRUCTION /_7 i <br /> ON / / PUMP REPAIR ^ <br /> PUMP INSTALLATION / / PUMP REPLACEMENT /� <br /> . a t Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ()o SEWER LINES S PIT PRIVY _ ^' <br /> SEWAGE DISPOSAL FIELD (ftl CESSPOOL/SEEPAGE PIT OTHER ;{N <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL P <br /> INTENDED USE UBLICrDOMESTIG WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIO •S <br /> Industrial I Cable ool Dia. f WellfExcavation tf r , <br /> Domestic/private 1 Dried <br /> Dia. o Well Casing _ <br /> Irrigation Domestic/public Dr en Gauge of, Casing �; C i4 <br /> Irrigation , Gr vel Pack Depth of Grodt Seal <br /> Cathodic Protection <br /> R tary jType of Grout <br /> Disposal 0 her Other Information <br /> Geophysical / 04V r <br /> - _ Surface'-'Seal Installed B � <br /> PUMP INSTALLATION: ContractorAd <br /> :. ' i -'•'a3 , <br /> Type of Pump <br /> H.P. i <br /> PUMP REPLACEMENT: / / S A_ rk Done i { <br /> PUMP 'REPAIR.-: -- e_ <br /> - _ <br /> DESTRUCTION OF WELL: 1 Diameter <br /> e cribe Material and Procedure Approximate Depth <br /> I hereby agree to comply w th all laws and regulations of the an Joaquin Local Health District' � 1 <br /> and the State of Californi pertaining to or uta re <br /> after completion of g ting well ��construction. Within FIFTEEN DA 5'� �! <br /> my wor onja new well, I will furnish the San Joaquin Local Health District, <br /> WELL 'DRILLERS REPORTof t e well and notify them before putting the well' in use.. The above <br /> information is true to th best of my knowledge and belief. iI WILL CALL FOR A GROUT INSPECTION <br />'RIOR-'TO GROUTING D A I L INSPECTION. <br /> SIGNED ` <br /> TITLE <br /> RAW PLOT PLAN ON REVERSE -SIDE) <br /> PHASE I V USE ON Y <br /> TPL.ICATION ACCEPTED BY „y <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II- GROUT INSPECTION <br /> rNSPECTION .BY PHASE II/FINAL :INSPECTION <br /> b 't 5`7 9� NSJ E�I N BY DATE :z-7 <br /> . E H 1426 v. 1-74 1 1„ i <br />