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5 <br /> b - _ <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> -y-0—F,-,OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> 'A, Telephone: (209) 466-6781 K <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _THIS PERMIT EXPIRES�I YEAR FROM DATE 'ISSUED Date Issued 5-s-,42 <br /> ' <br /> . (Complete In Triplicate) 22 ''_0&0•-1 <br /> Application is C reby 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ON ed .�s,a_, _Gds /,_ , �-�z�a- �i,,czl,�, ,pol CENSUS TRACT <br /> Owner's Name <br /> . �� _ Sr Sir _• � Phone <br /> r Address _ � � ��� �,.,� �,,,� City ., <br /> Contractor's Name / iy .2f-5 �'��� �1„ ,t,,,, License ��, fly Phonei?yJ7 <br /> a <br /> TYPE OF WORK (Check) :,_„NEW_WELL.,- _.DEEPEN,:-/�.-/- _.RECOND.ITION_-/--7- DEST'RUCTION-/7-7,­ <br /> PUMP INSTALLATION / / PUMP;REPAIR ,:/_,•/L'%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 - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE ,OF WELL CONSTRUCTION SPECIFICATIONS 111P <br /> Industrial1 <br /> Cable Tool Dia. of Well Excavation�/� - 5,2 ' /.,7 ' �a //1-(1 <br /> Domestic/private Drilled : Dia. of Well Casing f,[ <br /> Domestic/ ub`kid -- - Driven Gauge of Casin � <br /> _ Irrigation Gravel Pack Depth of Growl <br /> " <br /> Cathodic Protection Rotary Type of Grou �jf <br /> rDisposal °Other Other Information <br /> Geophysical Surface Seal Installed By: Alit-tS <br /> PUMP INSTALLATION:-' Contractor <br /> Type of Pump :.`� / `r�� H.P. <br /> PUMP REPLACEMENT: / / State 'Work Done : <br /> PUMP-,.REFAIR:� _ _ .. /_/ State Work Done <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 .Diatrict <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 GALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTIN AND A I N ECTION. <br /> SIGNET TITLE �,�,u. <br /> { . (DRAW PLOT PLAN ON REVERSE SIDE) U <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GRO T IN TIN PHAS Ii FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> { <br /> 2M <br /> a 77 . <br /> E H.1426 �ev. 1-74 - <br />