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>'A` pp�,/ / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '—OE- OFFICE USE: 16�E. Hazelton Ave. , Stockton, Ca m. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7G <br /> (Complete In Triplicate) <br /> 3plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .id/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 andt the Rules and Regulations <br /> of`the San Joaquin Local Health District. <br /> `1B ADDRESS/LOCATION `,/L ?� ( �I/)p111 (� ( / �^ 9th( (�/ �i3�dll2 '- /�T�-TRACT <br /> rwner's Name d/ ' wry("� `�� Phone _93X-,2AeT , <br /> Xddress aha ' City <br /> ontractor's Name OZ( 4 (7 License 11 _29e,9/.3`Phone ��?-JL3S/ <br /> YPE OF WORK (Check) : NEW WELL 071" DEEPEN / / RECONDITION /7 DESTRUCTION /-] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /—T <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK �`� SEWER LINES PIT PRIVY 0/dad/l Q <br /> SEWAGE DISPOSAL FIELD W+- CESSPOOL/SEEPAGE PIT OTHER 3AB <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLICDOMESTIC WELL T <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing d6" 1 5)V-1' <br /> Domestic/public Driven Gauge of Casing /LSO iay14 <br /> Irrigation Gravel Pack Depth of Grout Seal Ste` <br /> Cathodic Protection Rotary Type of Grout Rey?V-//AZA3 \ <br /> _Disposal Other Other Information �/ - 4 \ <br /> _ Geophysical Surface Seal Installed By: r� 11 6i.4 <br /> °UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r.'UMP .REPAIR: / / State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter 5 ef VOANIQJ Approximate Depth <br /> Des r beMate al and lyrocedure <br /> I hereby agree to aws an n s rict <br /> ind 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -- RIOR TO G OUTING- ANA INAL I PE ON. <br /> SIGNED _Zj [ TITLE Its �.Cw? ) <br /> (I) PI • PLAN ON WERSE SIDE) <br /> PHASE IlI 1"'1e <br /> V <br /> FOR DEPARTMENT USE ONLY <br /> ,r / f <br /> APPLICATION ACCEPTED BY . ' / hL ✓ DATE 91-2 7 r�-& <br /> ADDITIONAL COMMENTS: <br /> PHASE II ZNSPECTIOT PHASE III-/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY j DATE � _- <br /> _CfJ(¢ICG GREG ? 3/76 2M <br /> E H 1426 R v. 1- 4 <br />