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LOCAL 11EALTd <br /> FOR OFFICE USE: 1601 E. 11a7clton Ave. , Stockton, Cai- <br /> Telephone: (209) 46L-6781 <br /> APPLICATION i'OR FELL CONSTRUarm QI1 1,WILI rr'.R•:IT Permit No. Z-/SS/v <br /> THIS PERMIT EXPIRES 'L YEAR PROM DATE ISSUED Date issued =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 heroin described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules find Regulationa of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �S/G I' -,�•���e�+ CENSUS TRACT <br /> Owner's Name r L)r r:;.. <br /> Phone <br /> '•5-�'---- LI /hs,Dirac, <br /> Address /6'/Cc -Tackic,, (�c•l Ill..�i< ,, City 1 �1 . <br /> n c '.Li Phon f5- 3 YT G• <br /> Contractor's Name h)*'No ` I �� <br /> R' TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITiO- OU-CITION %7PUMP INSTALT.ATION /5U PUMP REPAIR / 1i�'t'�J ACEMENT �I <br /> Other /-7 , T' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW$R-'LINES PIT PRIVY <br /> ��. SEWAGE DIrROSAL F-IELD CESSPOOL/SEEPAGE TIT OTHER <br /> PRO "•Y IS�PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED <br /> OSE <br /> =0F WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excayation <br /> Domestic/private _ Drilled Dia. of Well Casing r <br /> Domestic/public Driven Gauge of Casing �p <br /> Irrigation _ Gravel Pack Depth of Grout Setl <br /> _Cathodic Protection Rotary Type of Grout I <br /> � Disposal _ Other Other Information <br /> �•• Geophysical Surface Seal Instilled B : <br /> PUMP 7NSTALLATION: Contractor <br /> V <br /> y Type of Pump <br /> C <br /> PUMP REPLACEMENT.- /% State Work Done (' <br /> I <br /> PUMP :REPAIR• L7 State Work Done W <br /> p <br /> pESTRUCTION OF BELL,; Well iometer - __ <br /> roximate Depth !� <br /> and--procednre---- <br /> I hereby agree to comply with all laws and regulations of the San Jo4quin Local Health District <br /> and the State of California pertaining to or regulating well conatruetion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San JoAquiu 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 beat of my knowledge and belief. I WILL GALL FOR A GROUT INSPECTION <br /> p PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE 13 Iii n.• <br /> x+ ' SIGNED DRAW PLOT PIAN ON REVERSE SIDE) <br /> �•- FOR DEPARTMENT USE ONLY .A <br /> r. <br /> PHASE Z <br /> APPLICATION ACCEPTED BY 6� DATE `,�7 �3-�� <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION _ II F �INCTION <br /> INSPECTION BY _ DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 1-74 2M - <br /> r <br />