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16Pr SAN JOAQUIN"LOCAL HEALTH DISTRICT <br /> FOk.OFFICE USE: ' 01 E. Hazelton Ave'' ,Stockton, Calif. <br /> Telephone: (209)• 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> fi <br /> THIS -PERMIT EXPIRE9 "1 YEAR FROM DATE ISSUED\ Date Issued =77 <br /> Applicat (Complete In Triplicate) <br />, ion is Aereby 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 raith San Joaquin <br /> County Ordinance No. 1862 and'�thh�e.Rules� and Regulations of the SanJJoaquin Local Health District. <br /> JOB ADDRESS/LOCATION / g � t2� E <br /> C NSUS TRACT. <br /> Owner's Name ' <br /> Phone <br /> Address .3 �4Gao . n.,f/_ Y "� 7`a�, � city . o�arawa—s-� <br /> Contractor's Name License #/ r'7 one <br /> Ejo <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR /,1c/ PUMP REPLACEMENT /77�._ Other / / ; . <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES iPIT 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 /> i 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° - , . - -2 MAI, H-.P. �s I <br /> PUMP REPLACEMENT / "/ State Work Done ' C <br /> PUMP.,,REPAIR:' State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe. Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health *strict <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 thein before putting the..well in use. The above € <br /> information is true to the best of. my—knowl g n lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OU ING AND A FINAL INS TION. <br /> SIGNED` - ac- e . <br /> �` ITLE <br /> 01, <br /> PLOT AN ON R RS E. SIDE) . <br /> PHASE I <br /> aR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 'Rev.- <br /> 1-74 177 2M <br />