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RSI SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO;. OFFICE USE: 1601 E. Hazelton Ave., Stockton. Calif. <br /> Telephone: (209) 666-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER111T Pernit Nu. 77-iDL 1P <br /> THISIPERMIT EXPIRES 1 YEAR PROM DATE ISSUED Dace Issued >ras,"» <br /> II (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a perOdL to construct <br /> and/or install the Work hexein'des<iLbed. This application is mode in compliance with San Joaquin <br /> County Ordinance Mo. 1862 and the Rules and Regulations of the Sao Joaquin Local Health District. <br /> JOR ADDRESS/LOCATION 010- //40)7 /-"� CENSUS TRACT <br /> Owner'a Naao � I r i na Phone <br /> Address /9 �1,�� /ny/Qy It/ /��� city^ i.plan <br /> Concracror's Nove !,?1.�JfF[1lI � License 1292 <br /> I e ; <br /> TYPE OF WORK (Check): NEW WELL L-7 DEEPEM 17 RECONDITION7 <br /> 1-7 DESTRUCTION f <br /> PU10 INSTALLATION L/ POMP REPAIR &q. —PL'PD' kEPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PST PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY SLIME - PRIVATE_MFST'C-WELL FCRILIC OCISESTLC WELL- <br /> IMTENDID USE TYPE OP WELL i CONSTRUCTION SPECIFICATIONS , <br /> Industrial I Cable Tool Dia.-of Wall Excevacion <br /> Domaacic/private I Drilled Din. of Wall Casing <br /> i-. Domestic/pubic. i Driven Gauge of Casing • <br /> _ Irrigation •1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout �p <br /> Disposal _Other Other Infornatton 'V7i <br /> -Geophysical Surface Seal Installed By; S" <br /> PUMP INSTALLATION.• Cmecrat for <br /> Tips:oe.ipW ,. _. ,�.r--_-__ -'K.P. <br /> PUMP REPLACEMENT: S•lute Work Donei�R i%�3 IIJ�� /L •7 YX4►' 4 1 <br /> t r <br /> PUMP REPAIR: L7 State Work Done <br /> Y <br /> OESTRUCTION OF WELL: Well Di,=ter -� r -i LAppfexSaste Depth <br /> Describe Materlal and Procedure <br /> I hereby agree to comply with all laws and resu ationa of the San Jeaqu"i Lotti tleaiih Giscrlec <br /> and the Scots of California pertaining to or re;ulet ln; well=ce,fitsuctlen. �Wlthin FIFTEEN DAIS <br /> after coaplecion of my work on a new well. L will famish the Ss Joaquin Local Health District a <br /> WELL DRILLERS REPORT o£ the wail and notify them before pulling the well in .uee. The above <br /> information &@ true to the best of my knowledge and belief. I WILL FOR A GROUT INSPECTION ' <br /> PALOR TOC TNG AFf A NAL 1SPEC -ON. <br /> SUED �_ I IUKAW PLOT PLAN ON REVERSE om SIDE '11 <br /> FOR DEPARTMENT L'SS ONLY w <br /> PHASE I 6 <br /> AFPLICATION ACCEPTED EY DATE <br /> ADDITIONAL COMPENTS: - <br /> PRASE TI GROUT TNSPECTION PHASE III I AL SPECT% N <br /> IRSPBCIlON BY DATE LNSPCGTION Rr--/ DATE <br /> 1177 _ 2l1 <br /> L N 1426 Rev. 1-74 - <br />