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1 <br /> l [i <br /> ! r SA;v sOAQUIN LOCAL iiEALT?? DISTRiC.; <br /> ri'Gn 'JF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r— Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION Ofi PUMP PERMIT Permit No. i:S= <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Dote Issued <br /> (Complete In Triplicate) <br /> Application is hereby mode to the San Jon-juin Local llealrh D' :rict for a permit to construct <br /> and, or install Lhe work herein described. This application is made in compliance with San Joaquit, <br /> Cou-ity Ordinan,_ No. 1862 and the Rules and Regulations of the--San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION Z �' x r �.�'� Y�+ %�'� 'n • Y' . CENSUS TRACT <br /> Owner's Name ��- T�1 -'`'� r r �.�. Phone <br /> AridresA �D C� r> "� ::,'� __ City <br /> license Phone <br /> Contr8ctoc s Name <br /> --r spa.ssaaa.ar_:sasax�-vaarssaim��—.mrmss-.-rr.».-"ktrsC:�^.-+rte.-:Yc...^_rc:z "'•'nc-t-acr-r.- <br /> - 1 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION I-T <br /> PUMP INSTALLATION / 7 PUMP REPAIR /�C—J~PUMP RFPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TAINK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD C!SSFOOL/SEEPAGE PIT OTHER 01 <br /> PROPERTY LLNF. - PkiVATF. $TIC WELL PUBLIC DOMSTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation (A <br /> Domestic/private Drilled Dia. of Well Caning <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal r OtherOther Information <br /> Ceophysital -! Surface Seal Installed By: <br /> FUM? INSTALLATION: Contractor <br /> T7pe of Pump ___.� R.P. <br /> r. <br /> REPLACEMFX7: L-7 Stnte Work Done <br /> {{ 1 <br /> P1 IMP REPAIR: A7 State W,)rk Dona <br /> RUCTION OF WELL: Well Diameter vApproximate Depth <br /> Describe Fiaterial and Procedure ;. <br /> 1 hereby wgrse to comply with all laws and regulntions of the San Joaquin Local Health District <br /> :i"d the State of California portaininR to or regulating well construction. Within FIFTEEN DAYS <br /> :,iter coupletion of my work on a nev well, I wIll furnish the San Joaquin Local Health District a <br /> 1,`LL DRILLERS, REPORT of the well And notify them b"fore plotting the well in use. The above <br /> Information la true to the best of erp.,krinwl.edge and 'belief. I WILL CALL FOP A GROUT INSPECTION <br /> "r71(�R 2-q__G(t0UTING,AN.Lb FINA_l. I�NSrFCi la 1. <br /> 1G*NEk �, fr/i - �_�._` �.� +�.._ _6 TITLE <br /> -- ID Pic N O RSE SIDE <br /> H J$PA.RTKENT USE ONLY <br /> !'lrASE i .s 7j'r �J <br /> Y DATE <br /> x.1`;'7,;CATIO:i ACCYPI'!;D R / _ �.�£r <br /> A`:D ITI ONAL GON.!'B'.N"rS: _._..___, - �_ <br /> _ w.....,..__,_...w .a.. PNASB m FINAL INSP_><CTION�. <br /> .•.,.,,,o,.,,... <br /> F4k..`:? '!'j f"'°111 i:�..: ..._,� ...,.:: <br />