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- 4,4e ,6_6 SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OFFICE 1jSz 160' E. Hazzlton Ave , Sto(kton, Calif <br /> ' Telephone (209) 466-6781 <br /> APPLICATION FOR WRLL CONSTRUCTIOA OR PUMP PER 11T Permit No <br /> TRIS PEEMIT EXPIRES 1 YEA$ FROM DATE ISSUED Date Issued i/__/�_2/ <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 /> r .TOB ADDRESS/LOCATION —��.0Z2 r,�4F, . �irf ��rs-�) _ CENSUS TR..CT <br /> y Owner's Name o r `fie�� _ Phone <br /> Address laay c r � f.�� hR� City G✓1 <br /> s <br /> Contractor's Na / License ,j-3 Phone 'a -74,761 <br /> i — i <br /> tq L <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECON:rITEON /_7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR /)C/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTTER <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCLION SPECIFICATIONS N` <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Crying <br /> ' Domestic/public Driven Gauge of Casing <br /> A _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> ' <br /> —Geophysical Surface Seal Installed Bim. w Y <br /> r PUMP INSTALLATION: Contractor / A <br /> Type of Pump _ . .. ✓ -- H.P. 5 <br /> z r <br /> PUMP REPLACEMENT: / / State Work Done k <br /> ' <br /> PUMP REPAIR: State Work Done <br /> s DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> y , <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <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 them before putting the well in use. The above <br /> in!ormation is true to the best of myledg�e2and elief. I WILL CALL FOR m GROUT INSPECTION <br /> PRIOR TO GROUTI AND A FINAL INSPYQ.,I <br /> SLGNED `^ �.i TLE / _. •_ j <br /> PLOT PLAN ON RMfMSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> IJ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: / <br /> PHASE II GROuT—INUERKION PHASA VI F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y G <br /> ti E H 1426 Rev. 1-'74 <br /> V +3�7 <br /> tvzqK <br /> r <br />