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SAN JOAQUIil LOCAL lUiAL1'H DISTFICT ya/' <br /> ` FOF OFrICE USE: 40 1601 E. Hazelton Ave., Stockton, i&f. <br /> Telephone: (209) 466.6787. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> -7-1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /l---2,F <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 the ules Vd Reyu Sons f the San Af!oquin. Lxal Health District. <br /> Al 0 <br /> JO DRESS/LOLOT �� S f �� c / �E,pf; N/� 15,P1D69,t4- CENSUS TRACT <br /> /A 1, <br /> / <br /> Owner a Na��u/-L�- -/�--� Sty � -2/Yl� CFYl-/�+ Phone 9V7- 3q,� <br /> Address 7/� IYu�n�Ov—�[�y©�•/ SNC. City(S'L1 �C�¢ TCA, <br /> Contractor's Name f7'T'//1� I� jM /51 �J---,) c�c'mL�/... License,Yi� S- Phone <br /> TYPE OF WORK (Check): NEW WELL /7r DEEPEN /7 RECONDI—TION /7 DESTRUCTION L/ <br /> PUMP INSTALLATION /PUMP REPAIR /% PUMP REPLACEMENT /� Z <br /> ! Other <br /> DISTANCE TO NEAREST: SEPTIC TAN d -f-- SEWER LANES_ --f--PIT PRIVY <br /> SEWAGE DISPOSAL FIELD.(CESSPOOL/SEEPAGE PIT Aro7r{OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL �s <br /> INTi_rDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> _ Industrial Cable Tool Dia. of Well Excavation CA <br /> - � <br /> ;domestic/private Drilled Dia. of Well Casing l S- <br /> j _ Domestic/public _ Driven Gauge of Casing <br /> _ Irrigation _ Gravel Pack Depth of Grout Seal <br /> { _ Cathodic_ Protection --iGtary Type of Grout ,6N/-on,/-t v'- CVAs Q. <br /> I Disposal Other Other Information Sy_„q„q -7�o P.• - o, <br /> # Geophysical Surface Seal Installed By: <br /> 1 i PUMP INSTALLATION: Contractor-�� / ✓�K f/ � �V <br /> Type of Pump fS•`�� _ H.Y. <br /> I +�: PUMP REPLACEMENT: / / State Work Done <br /> - — <br /> 77— <br /> PUMP .REPAIR: /-7 State Work Done <br /> i <br /> 1 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 /> 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informs on is true Co the knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO OUTING AMD A N I S I _ <br /> TITLE �c—Fy—(V r� r) r <br /> W PLOT PLAN ON REVERSE SIDE T �' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE• <br /> _ <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />