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�P1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0& OFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �a <br /> 7,6 -spa <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued 6-30-79 <br /> (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 /> .708 ADDRESS/LOCATION 5;t 769 CENSUS TRACT <br /> Owner's Nannie �ec7y" �'`cvrfd Phone /�J/— za z <br /> Address ... _ - .-�- .. City -j/C7 r�G/S <br /> Contractor's Name <br /> License7?� Phone (; 0494 <br /> TYPE OF WORK (Check): NEW WELL '_ DEEPEN -/7 RECONDITION %T DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR1/� PUMP REPLACEMENT <br /> t Other /-7 <br /> DISTANCE TO NEARESTVSEPTIC TAN E SEWER LINPIT PRIVY <br /> SEWAGE DIS IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED UST TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation O k <br /> Domestic/private Drilled Dia. of Well Casing �« <br /> Domestic/public Driven Gauge of Casing _. CI-/G.,00 / C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary "Type of Grout <br /> 'P4 Disposal Other Other Information -- -- <br /> Geophysical `Sur€ace Seal Installed 'By: p a c <br /> PUMP INSTALLATION: Contractor e"ae_1 C� /C-, --.Z<7 �- <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: /-7 State Work Done d . <br /> )ES•TRUCTION OF WELL: Well Diameter 5 Approximate Depth <br /> Describe serial and Procedure 9 <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-Oe 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 GRO RF <br /> SIGNED --CdTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE 1 <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ,`APPLICATION ACCEPTED BY, DATE ' <br /> ,;.ADDITIONAL COMMENTS: <br /> PHAS '-II G UT M,PEMIOW. PHASE I FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E h$. 1426 Rev. 1--74 75 2M <br />