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FOR OFFICE USE: 1601 E. Ha`zeltof"'O 4 Stockton, Calif. <br /> Telephones„,.I ,,,....7 X466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 � <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 1,4 t 1 s an e u tions the San Joaquin Local Health District. <br /> "JOB ADDRESS/LOCATION 4Z? �. - �/�` �-,a K� �(,.�.a- / - CENSUS TRACT <br /> l �'�l- vt C. Phone ' <br /> �-� <br /> Owner's Name �-� � �1^d�' #- �.� 3 <br /> Address - - - .� f �l--a ,.,.. L.tr` ... ._,.. City <br /> Contractor's Name f er 0 �•p j- /�{ llj�,yti License �� Pkone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / — — — <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -, — OTHER <br /> PROPERTY LINE '- PRIVA�MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . . <br /> Industrial Cable Tool Dia, of Well Excavation f <br /> Domestic/private Drilled. Dia, of Well Casing <br /> Domestic/public Driven `� Gauge of Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout. <br /> Disposal 3 Other Other Information a- AVA PI— <br /> Geophysical. tSurface Seal Installed By: <br />. PUMP INSTALLATION: Contractor <br /> a <br /> - Type of Pump �' H.P. <br /> PUMP REPLACEMENT: / / ^ 'State Work Done jar <br /> PUMP .REPAIR: / a/ . St'ate Work Done 4 <br /> DESTRUCTION 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 /> kand the State of California pertaining to or regulating well '-construction. Within FIFTEEN DA ,S <br /> Fafter 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 :putt'ing the well in use.. The above <br /> information is true to the best of my knowledge and 'beli '� <br /> ef..� I 'WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G A FIN INSPECTION. { 11 <br /> SIGNED TITLE <br /> l4bRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMEN7 USE ONLY <br /> J PHASE I �` <br /> APPLICATION ACCEPTED BY C. (�/ ATE <br /> ' ADDITIONAL COMMENTS: 3., ._E t <br /> ` PHASE Il ROUT INSPECTION - PHAS I /FIN INSPECTION <br /> INSPECTION BY c'` DATE - INSPECTION BY DATE -7 <br /> E H 1426 uPu_ 1-7L /y�� 2a <br />