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l �- SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> ,FE ' OF CE USE: 1601 E. Hazelton Ave. , Stockton', Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> �ia QQ <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE"ISSUED Date Issued 9/6-77 <br /> I (Complete In- Triplicate) Y <br /> Application f6 hereby made to the San Joaquin Local Health District for a permit to construct;` <br /> i and/or, install the work herein,.described: ' This application is made in compliance with San+Joaquin <br /> f County Ordinance No. 1862 and the Rule' and Regulations of the -San Joaquin Local Health District. <br /> F JOB ADDRESS/LOCATION ) / y 9• A474o0*)w,%e CENSUS TRACT <br /> IOwner's Name (7( p,� � v�m7,. Phone f <br /> fAddress <br /> City <br /> r <br /> r + <br /> Contractor's Name License # 65% phone <br /> TYPE OF WORK (Check) ; NEW WLL' /._/ DEEPEN/7 RECONDITION /% DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /fe/ PUMP REPLACEMENT <br /> Other !/ / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY G1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL 1 �: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �+ <br /> " Domestic/public Dri_v_gn,. _ F .:Gauge of -Casing <br /> Irrigation '' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal ! Other ,,Other Information <br /> Geophysical Surface Seal' Installed By <br /> - <br /> MP INSTALLATION: ContrBntor f t <br /> Type b} Pump st �- <br /> PUMP REPLACE <br /> NT: / / State Work Done <br /> , s MEt <br /> PUMP .REPAIR: be State Work Done / <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the- San Joaquin Local Health District 1 <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 <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 oSPEf <br /> PRIOR TOG my N owled ah elief. I WILL GALL FOR A GROUT INSPECTION <br /> U ING AND A FINAL IN <br /> SIGNED TLE <br /> ! RA PLO P ON RE E SIDE) �� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> AP CATION ACCEPTED BY` DA <br /> TE ASE I ATE ( / 6 <br /> 21 000 <br /> INSPECTION V <br /> A IONAL COMMENTS: - -3�= ---. <br /> U}!!T,ZN .. CTbON., -�- .PHASE,_ II/FINAL.d SPECTION J <br /> BY -- DATE INSPECTION BY DATE <br /> it—AH 1_426 1 Rev. . 1--74 0/77 'Omc''�'/ <br />