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i <br /> ` N JOAQUIN LOCAL HEALTH DISTRI( <br /> USE: <br /> 16 E. Hazelton Ave. , Stockton, Callf. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ti 73 <br /> 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /E 9/� <br /> I //-7ti <br /> (Complete In Triplicate) <br /> .plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ,rad/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JB ADDRESS/LOCATION 73 `K S- ���_ moi_ t�— I CENSUS TRACT <br /> rner's Name 4j] ,PAIS �c/ <br /> ��� Phone _��/moo ` / <br /> Address / Ca 17 /S' City S e f* �� f <br /> tntractor's Name ^ '' <br /> /�'�``� ""F %���" _ License 11 Phone <br /> 'PE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / — <br /> _:STANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES �-o PIT PRIVY <br /> SEWAGE DISPOSAL FIELD v CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L, <br /> Industrial Cable Tool Dia. of Well Excavation / <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing „S - y . <br /> Irrigation Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: C'aoYic r <br /> I"'MP INSTALLATION: Contractor <br /> Type of Pump ✓,.1 H.P. <br /> f <br /> Pt MP REPLACEMENT: / / State Work Done <br /> PaMP REPAIR: / / State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> jr hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d 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 /> JFLL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> i formation i true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> '°niOR TO G NG AND A FINAL CTION. <br /> iIGNED TITLE <br /> W PLOT PLAN ON REVERSE ----- <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I <br /> PLICATION ACCEPTED BY r% l DATE -,7 <br /> ! _DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> "SPECTION BY } DATE INSPECTION BY DATE ' <br /> 6 � / <br /> E H 1426 <br />