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L SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> Foi�;OFFICE USE: 601 E. Hazelton.Ave. , Stockton, -Calif. <br /> I Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z -J3.;W, <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED .Date Issued 3-1/-76 <br /> (Complete In Triplicate) <br /> Application is hereby made td the San Joaquin Local Health District four a permit to construct <br /> and/or install the work herei .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 /> o <br /> JOB ADDRESS/LOCATION s.7n*-Le "C CENSUS TRACT <br /> owner's Namedeer µPhone d -z 3, � 9 <br /> Address • City 'a . <br /> Contractor's Name ---. License #1� 3 Phone36 <br /> TYPE OF WORK (Check): NEW WELL /_' DEEPEN '/7 RECONDITION f-7 DESTRUCTIONS f7 <br /> PUMP INSTALLATION REPAIR ' PUMP REPLACEMENT 17 4 <br /> Other /�:/ <br /> Y _ _ <br /> DISTANCE TO NEAREST:.--:- SEPTIC TANK SEWER LINES 1' PIT PRIVY � <br /> *SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL P_UB.LIC .DOMESTIC-.WELL <br /> ` --1NTENDED-USE— TYPE OL' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial; }} Cable -Tool Dia..-of,Well Excavation <br /> Domestic/pr.ivabe Drilled Dia. o€ "Well Casing I <br /> Domestic/public Driven Gauge of Casing } ; <br /> Irrigation ` w Gravel Pack Depth of- Grout Seal i t <br /> Cathodic Proredjt on Vi� Rotary Type 'o`£ Grout 1 <br /> Disposal ` Other E 1 . Other Information t <br /> Geophysical .._ Sur€ace !Seal 'Installed BY: _ <br /> PUMP INSTALLATION.-�-- Contractor <br /> Type o€ Pump s H.P.— <br /> PUMP RE]AACEMEI: / / State Work Done <br /> PUMP .REPAIR: `� � .' �/" .State Work Done P '. <br /> D LWELL.• Well Diameter ' ' Approximate De th <br /> ES TRUCTI'ON QFp <br /> Describe Materia, and Procedure <br /> j 3 <br /> I here y5'4reefto 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.,GROUTI A V1 <br /> Ad' INSPE ION. <br /> SIGNED ". i TITLE <br /> by RAW PLOT PLAN ON REVERSE SIDE) <br /> j FOR DEPARTMENT USE' ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY 1 .��. DATE �h <br /> ADDITIONAL COMMENTS: <br />! PHASE II GROUT INSPECTION- PHASE III/FIN",-INSPECTION <br /> ti <br /> INSPECTION BY DATE INSPECTION BY ✓ DATE <br /> E H 1426 Ray. 1-74 rr ' 2M- <br />