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SAN 1QUIN LOCAL HEALTH DISTRICT <br /> J OFFICE US 1601 E-Slm�yelton Ave. , Stockton, Calif. <br /> *400 <br /> �— Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7k-.,2,731 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued;;2 ".;29"'7d <br /> In <br /> 11 cation is hereby made to the San <br /> (Complete <br /> for a permit to construct <br /> [/.r install the work herein described. This application is made in compliance with San .Joaquin <br /> inty Ordinance No. 1862 andhe Rules and Regulations of the San Joaquin Local Health District. <br /> .)DRESS/LOCATION r " E/�s7"Si�c of Sca/rt, .voa;ii c,r ,cj;,r�C'NSUS TRACT <br /> errs Name I7.4C 1< 4- L Phone <br /> -- c3'z sr <br /> rfts2 .io Soe.�L1Z4D'S <br /> - � -- — City — <br /> tj ctor's Name License #,F,pgPhone�W- 7 <br /> Z <br /> E F WORK (Check) : NEW WELL / / DEEPEN /-7 RECONDITION /� DESTRUCTION /-7 9.J <br /> r PUMP INSTALLATION /L./---gUMP REPAIR /% PUMP REPLACEMENT /7 W <br /> Other <br /> Pp CE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY — <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS VA <br /> _*ndustrial Cable Tool Dia. of Well Excavation G <br /> _ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _� Frrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> _ 'lisposal Other Other Information <br /> .:eophysicaJ. <br /> Surface Seal Installed By: <br /> _TVSTALLATION: Contractor S �3'I � is pcC <br /> Type of Pumpt6�yic�Si/3/� -- H.P. <br /> r <br /> REPLACEMENT: / / State Work Done <br /> .PAIR: / / State Work Done <br /> !L -TION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> --------------- <br /> re�y agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ll State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r Tompletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> rir tion is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> r) GROUTING AND A FIN PE917 N. <br /> 3D San <br /> TITLE rn;.;.:,,,, <br /> =1 <br /> (DRAVI P PLAN ON REVERSE SIDE) <br /> 711 H <br /> L FO DEPARTMENT USE ONLY Lodi, Cali'rnnnia 9--2 io <br /> I _ <br /> :C PION ACCEPTED BY DATE <br /> COMMENTS: — " <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> 3C°'ION BY DATE INSPECTION BY i <br /> DATE <br /> H 1426 Rev. - I-74 6/77 2M <br />