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je", SAN JOAQUI.N LOCAL HEALTH DISTRICT <br /> POE OFFICE USE: 1601 E. Harelren Ave., Stockton. Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit so. 7-1-/dL 1P <br /> THISIPERI(IT EXPIRES 1 YEAR PRO" DATE ISSUED Date Issued jar•» <br /> I (Complete In Tr/plicate) <br /> Application Is hereby made to lthe San Joaquin Loeai Health District for a permit to COnat"CL <br /> and/or install the Werk hereinldeseribed. This application is mode in compliance with San Joaquin <br /> Cavnty Ordinance No. 1062 And be Rules aeg <br /> nd4 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSILOCATION /� � p,_w + CENSUS TRACT <br /> nn 1 <br /> Owner's Name &a1L /.-7f/_ Ina Pbona f .�q <br /> Address �7��r/ //Y�IV �e�:/Q _.. City /,1'0292Q_ - <br /> Coaeraeeer's newt ✓J ��fT/J!1 �/'% License 1' ` one f <br /> �I <br /> TYPE OF WORK (Check): NEW WELL D DRUMM /-7 RECONDITION /-7 DESTRUCTION (7 <br /> Pump INSTALLATION L7 PLINP REPAIR kf-rim REPIACP1gPs /7 <br /> Ocher /i1 <br /> I � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ 1 PRIVY <br /> SAL FL <br /> SEWAGE DISPOIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PXIPF,RTY luNE - PRIVATE DDMESTIC WELL — PUBLICS LSC WFLL!— �. <br /> INTENDED USE TYPE OF WELL ! CONSTRUL71O SPEC-IFLCATSCNS oA, <br /> Industrial I Cable Tool Dia,of Well Excavation �I <br /> Domestic/privare 1 Drilled Dia. f Well Caging . <br /> Domestic/public I Driven Gaug4Fof Casing <br /> i irrigotlon •I Crewel Pack Depth of Grout Seal Jul <br /> Cathodic Protection I Rotary Type of Grout %]Bg <br /> Disposal Other Other Information <br /> —Geophysical Swrface Seal Installed Bv: <br /> i <br /> PUNP INSTALLATIOXI� MCanerac'tar <br /> _ ype. Pump �• ..�. 1 �+ ,,rte �� �I <br /> PUMP RIPLACRIOCKT: State Bork Done �l /�l� ��j { -JT/1/� 1LXLt�� 61 <br /> PUMP REPAIR: L-7 Stilts Work Done - <br /> r ' <br /> DESTRUCTION OF YELL: Well Dli ter �.i � ilAppiosimeta Depth <br /> Desertbi Llaterlal and Procedure <br /> I hereby agree to camply with ilii taw cad regulations or thm San Joaquin Loul soolth District <br /> and the Scats of Cslicornia pertaining to or regulating ve3l=gonstsuccida. Within FIFTEEN DAYS <br /> of ter completion of my work oma A naw wail. I will famish the Sad Joaquin Local Kcalth District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in was. The above <br /> information M true to the best of my knowledge and helief. 1 WILL CA4 TOR A GROUT INSPECTION I F <br /> OA F15PE <br /> PLOT LN I TIT- <br /> 5IG"EDffiC ASEE DE_ : <br /> ' I <br /> ".F'. I PDR DEPART"PNT ISE ONLY _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY BATE - !>� <br /> ADDITIONAL COMMENTS: <br /> PHASE I1 GR UT SPECTION PEASE III FINAL INSPP-CTI_._fM , <br /> INSPECTION BYATE INSPECTION NY , E <br /> DAT <br /> E H 1426 Rev. 1-74 1177 . 211 <br /> i <br />