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1,0';Ai, 11EAL�i <br /> FOR OFFICE USE:�. _ 11rL60-i. t.. Hazelton Ave. , Stockton, Cal.L . <br /> Telephone: (209) 466-6781 <br /> 01%1CATION FOR WELL CODSTRUCTION 0A PUMP PERMIT Permit No. q/G 4) <br /> Tim PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued —Z l <br /> (Cornpletc In Triplicate) <br /> Application is hereby made to Lire 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 /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Sout'r Viol;land lid. c''%' ` ` <br /> __ CENSUS TRACT <br /> ( Owner's Name �, �' l g Phone <br /> Address X City <br /> Contractor's Name =ennn s terns . nb Co. inc . License # X13 Phone 52�'-1031. <br /> Jur. <br /> -am iD Ie : odes -o e-7!T--- 9035`^) <br /> TYPE OF WORK (Check) : NEW WELL /' DEEPEN ;_ / RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> " DISTANCE TONEAREST: SEPTIC TANK SEWER LINES PIT PRIVY St <br /> SEWAGE DISPO, LL'—FIELD CESSPOOL SEEPAGE PIT OTHER e <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS -4 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing 6 5 Lrt� <br /> Domestic/public Driven Gauge of Casing ra <br /> Irrigation Gravel Pack Depth of Grout Seal �� <br /> Cathodic Protection X Rotary Type of ,Grout Rentnni to <br /> Disposal Other Other Information Slab b-,.T owner <br /> Geophysical Surface Seal Installed By: -;rii l pr <br /> PUMP' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 27 <br /> PUMP :REPAIR: / / State Work Done ' <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 the 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 OUTING AND A FINAL SPECTION.' <br /> SIGNED TITLE <br /> (DRAW PLO ON RE.V__FR-9F SIDE) <br /> FOR DErAWMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED $Y _ Z, DATE 7� <br /> ADDITIONAL COMM i <br /> P r I UT INSPEC'��N,�_ P / INAL INSPECTION <br /> INSPECT-1 BY DATE �� -,� INSPECT ON B DATE <br /> E H .1426 Rev. 1-74 1-7A W <br />