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SAN JOAQUIN, LOCAL, HEALTH DISTRICT' <br /> F'OR;OFFICE USE: V 1601 E. Hazelton Ave: , 'Stockton, Calif. <br /> Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-5'-- j-VUJ <br /> j . .. <br /> THIS PERMIT MIRES. 1.XEAR .FROM DATE ISSUED Date Issued �/3-75- <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. 3862 and the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION old E�NSUS TRACT <br /> Owner v s Name Cmc-�/�� Phvna -- <br /> Address . --�_ _.- City / <br /> r <br /> Contractor's Na m / Lice pe �1 Phon `j <br /> /c3 — 7 <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN -17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ , UMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other / / &400116 <br /> .61611996ZL <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTTARIVY <br /> SEWAGE -DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OVER GAF -- <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL R} <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS .� <br /> IndustrialL-- Cable Tool. Dia. of Well Excavation ().) <br /> Domestic/privAte Drilled Dia. of Well Casing .pd <br /> D stic/public Driven Gauge of Casing _ /� <br /> Irrigation Gravel Pack 'Depth of Grout Seal — <br />' Cathodic Protection Rotary Type of Grout <br /> Disposal Other --Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contradtor -�. . <br /> Type of Pump / H.P. jam_ <br /> PUMP REPLACEMENT: - / / State Work Done <br /> ,..� <br /> PUMP : ne �&9422L=--.REPAIR : /7 State Work Do <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> -Describe Material and- <br /> -Procedure--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 he-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T'0 GRO NG FINAL INSPECTION. i <br /> SIGNED •� TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> _ _FOR_DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS, R <br /> PHASE II 'GjkOUT INSPECTION PHAS5 III FINAL INSPECTION <br /> INSPECTION BY /,� _ DATE INSPECTION BY DATE <br /> H3.426 1 <br /> 1426 -74 1-7+�2M <br /> - - � 4 <br />