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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 9FFICa USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 7-/805 <br /> t� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued``��'TT <br /> I (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 /> JOB ADDRESS/LOCATION /Q SSD -91 r�GLG7l7t©q�R(Y CENSUS TRACT t <br /> I`{{{ <br /> Owner's Name _q r�o5'�7l3 �(lPs d7 Phone O <br /> I <br /> Address �� �� S'.'Jai h,7,— lQ� city /1ja y fe etL <br /> Contractor's Name � Qh,lnr.c rpE s��`\rc �., License # 'Zcp�13 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ J RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other J / <br /> DISTANCE TO NEAREST: -/SEPTIC TANK/ZD rj-SEWER LINES 17y PIT PRIVY <br /> �/ SEWAGE DISPOSAL^ LAV CESSPOOL/SEEPAGE PIT _ OTHER <br /> /� -ri PROPERTY LINEIDw PRIVATE DOMESTIC WELL/LG PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1/ Domestic/private Drilled Dia. bf Well Casing /"py c, 16 7 (n <br /> Domestic/public Driven Gauge of Casing <br /> i_ V Irrigation Gravel Pack Depth of Grout Seal 'so' <br /> Cathodic Protection Rotary Type of Grout zerkn^.J.Q <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 62f A,#- } <br /> : <br /> Type of Pump A.P. <br /> (PUMP REPLACEMENT: / / State Work Done <br /> ,PUMP .REPAIR: - / /. State Work Done <br /> LDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <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 /> 'information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDLiS�'-P1�iYt TITLE <br /> —� (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR Y <br /> DEPARTMENT USE ONLY U ' <br /> (PHASE I <br /> APPLICATION ACCEPTED BY 1 DATE <br /> 'ADDITIONAL COMMENTS: <br /> PRAS + II GRQPT INSPECTION P S I FIN INSPECT ON <br /> INSPECTION BY 1 DATE 97 INSPECTION BY ATE <br /> I 1\ i <br /> . A_C� f 6 1f.I7 _ 2MZ. <br /> n <br />