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ti <br /> SAN JOAQUIN L(IF:A 1. HEIAI.'IH DISTRICT <br /> OR OFFICE USE: 1,601 E. Haze.)Luce• P,ve. , Stockton, Calif.' <br /> TeL2phone; (2O9) 466-6781 <br /> APPLICATION FOR WELL (:�''f!:TRUCTION OR PUMP PERMIT Permit No. I—/,5'y/ <br /> THIS PERMIT EXPIRES 1. YEAR FP.OM DATE ISSUED Date Issued I/-11�'1�s" <br /> (Con'pi. :t.e'la Triplicate) <br /> Application is Aereby made to the San Joaquin Local 11calth District for a permit to construct <br /> r; and/or install the work herein descril-ed. I},i:; application is made in comps iance with San Joaqutin <br /> �+ County Ordinance No. 1862 and the Rules ant! of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �S^ r, rs�tt' CENSUS TRACTZI <br /> _ t <br /> p Owner's Name �ll%r��_`;' ... . -- Phone t <br /> 3 Address �G' �� � '� .— Cit} J <br /> r <br /> Contractor's Name r t• f `� ''� License # l� hone <br /> ' 1 N DESTRUCTION /"T <br /> # TYPE OF WORK (Check): NEW WELL /k� DL[.]'I;fJ £ RE,CO.14D1TI0c1 / <br /> -j ia' KEI'AIR PUMP REPLACEMENT /? . <br /> PUMP INST LrITION /f'�,� / / � <br /> Other <br /> fi <br /> DISTANCE TO .NEAREST: SEPTIC TANK _ 51-;1'.P!' } Ja',S _ PTT PRIVY <br /> } SEWAGE DISPOSAL F1E1_U CESSPOOL/SEEPAGE PIT OTHER <br /> ' _ -C%5_ 1a ?1ET IC DOME INE - 1'K1' : P STIC WELL <br /> INTENDED USE TYPE OF WI:LI., CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable T'co3 Dia. of Well. Excavation 40 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> sIrrigation Gravel P,,-,.1 Depth c` Grout Seal � r <br /> Cathodic Protection Rotary Type of Grout <br /> rOther Informat on <br /> Disposal <br /> Other <br /> GeophysicalSurface Seal. Installed <br /> PUMP INSTALLATION: Contractor r -�:'_ _ _ -L <br /> e Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Don_(l. <br /> .A <br /> PUMP ',REPAIR: / / State Worlc 1)oa;r <br /> DEST�RUCTION OF WELL: Well. Diamater __ _ Approximate Depth <br /> Describe Material ar 3.'!', zciure <br /> 'r. <br /> i I hereby agree to comply with all laws and rens of the San Joaquin Local Healt'n District <br /> �• and the State of California pertaining to o> rt'v !.a .:Lng well construction. Within FIFTT;EN DAYS <br /> after completion of z^y work oit a new well ,. I vi:fl [tarnish the San Joaquin Local Health District a <br /> i WELL DRILLERS REPORT of the well and notifyputting the well in use. The above <br /> informationis true to the best of 11,y lcnow.l°' ! ." = <br />