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r <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone`:,,� �(209) ' 466-6781 <br /> L.APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? <br /> (Complete In Triplicate) <br /> I Application Ys hr'—eby 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 Joaquii <br /> E County Ordinance-No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> S <br /> ' JOB ADDRESS/LOCATIONCENSUS TRACT , <br /> ` ' <br /> Owner s Name/ p_,�,� �'N f,t Phone <br /> Address <br /> City , tdle��t <br /> V4tl/e .w�A9&11�►i/ r jd Cep 1911 .3 X66- 96Z <br /> Contractors Name .License ��` Phoas <br /> TYPE OF WORK (Check)" NEWELLDEEPEN /_/ RECONDIT.IOF� /�-.,DEST-RUCTION /-7, <br /> UMP -INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> her <br /> no <br /> t L- <br /> D CE EU O TF,Ai�j `SEPTIC TANK /�_ SEWER LjNES PIT PRIVY <br /> J SEWAGE DISPOSAL FIELD tep + CESSPOOL/SEEPAGE PIT OTHER . , <br /> ROPERTY LINE=- PRIVATE DOMESTIC WELL. TO PUBLIC DOMESTIC WELL <br /> SA k.r"- TYPE OFZWELL CONSTRUCTION SPECIFICATIONS , <br /> `-. l t <br /> Cable Tool Dia, of ,Well Excavation <br /> ` Doinest'ic/private . Drilled Dia. of Well Casing _ 12 x <br /> Domestic/public Driven Gauge of;��Casing �� �(" <br /> Irrigation' ',- i ^' . Gravel Pack Depth of i Grout Seal AV <br /> Cathodic Protect-ion Rotary Type of Grout <br /> E Disposal - Other Other Information <br /> Geophysical� �' Surface Seal—Installed BY: 3 <br /> PUMP INSTALLATION: :, -� Contractor; 5 <br /> Type Of P <br /> �.. ump k i H.P.... <br /> .. <br /> PUMP REPLACEMENT: / Sta4 t_ ,'Work Done - r <br /> r-. <br /> fll� <br /> PUMP :REPAIR: 7 to kDar��HS LAP ••• -� - <br /> lio <br /> DESTRUCTION OF WELL: :Well r w Td, Ag�roxi ate Depth . <br /> Describe M ter a dProcedure <br /> ` i <br /> I hereby agree to compl with all: laws a d g tions of the San Joaquin LVe. <br /> h :bistriet <br /> and the St California pertaining to or regulating well 'construction. IFTEEN DAYS <br /> F after co pletion o my work on arne well, I will;furnish the San Joaquin Lalth District a <br /> WELL DR LLERS REPOR of th we 1 d notify them before putting the .well inThe above <br /> informs ion. i tr to he b f y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR AND F CTION <br /> SIGNED. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY D <br /> PHASE z <br /> APPLICATION ACCEPTED BY J DATE ,P <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I / INAL INSPECTI N <br /> ' INSPECTION BY^ - DATE INSPECTION B DATE � .� <br /> E H 1426 Rev. 1-74 2K 2 <br />