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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx:O ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-S-5`8p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ) 9�.5_ <br /> (Complete In Triplicate) 7- 05v -O� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> rind/or install the work herein described. This application is made in compliance with San Joaquin <br /> County_.Ordinance No. 3.862 'end the Rules and Regulations of the San Joaquin Local Health District. <br /> 4I roAa o.� &1-0JOB ADDRESS/LOCATION <br /> ��r�r Ia1�ip i4r�et,/,fm bc? aa" W, CENSUS TRACE .; <br /> Owner's Name �! Phone <br /> } <br /> Address -7 X71yI 'OQ �a� - ,.. ._ ;City <br /> Contractor's Name v License #, ;-.`Phone <br /> TYPE OF WORK (Check): NEWi�WELL /? DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/- <br /> <7 PUMP REPLACEMENT f"7 <br /> QS <br /> Other /_7 f <br /> JI <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY,— <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '—. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X. i. Cable Tool Dia. of Well Excavation <br /> X _ Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven . Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic •P'r_otect_ion Rotary Type of Grout ' <br /> Disposal Other . Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. -:2L-- <br /> PUMP REPLACEMENT: / /I� State Work Done <br /> PUMP '.REPAIR:' � State Work Done �, / � � <br /> .. r�tim /�db9s� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> P 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 anew well, I will furnish the San Joaquin Local Health District a <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.of ow edge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UING AND A VINAL IN ION <br /> SIGNEDITLE <br /> OlePt�zl LAN ON _ ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APLTCATION ACCEPTEDBY DATE ZZ,/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE -III/FINAL INSPECTI N <br /> iN5PECTTON BY -1I DATE INSPECTION BY / DATE . <br /> __-... . <br /> . _ <br />' <br /> 9 ii 1426 Re_,v. 1-74 � I" - - -- 4/75 2M...._ <br />