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SAN JOA UIN LOCAL <br /> Q HEALTH DISTRICT <br /> FOE.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `7s--L�;W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �F­/o` 7.5_ <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 CENSUS TRACT . ,' f i <br /> Owner's NameLOA Y/V4=__ ,L t �9/9 `�` Phone��1'09�LI <br /> Address city�%� �"dl \j ' <br /> Contractor's Name /4' G�ijC3� License / �-`37� Phone�4""7G0( <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/? RECONDITION /?7 DESTRUCTION %j µ <br /> PUMP, INSTALLATION/ / PUMP REPAIR � PUMP REPLACEMENT /7 <br /> Other / 7 / evA:/ L2� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ...,..,. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP : <br />