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y' y <br /> C <br /> SAN JOAQUIN LOCAL. IIf.A1,'!; D1S,(:2IM 7; <br /> 0iF OFFICE USE: 1601 E. lUazelton Ave. , Stockton, Calif . <br /> Telephone: (209) 566-6181 <br /> APr L-ICATION FOR WELL CONSTRUCTION OR PUrII' PEP.::1T Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSVEn Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby mi- to the San Joaquin Local 11calth District for a permit to constr.i:.t <br /> and/or install the w`%e nerein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1662 and the Rules and Regulations of the San Joaquin Lotal Health Diatriet. <br /> JOB ADDRESS/LOCA/Ion —r-: {%�1 �1 )d' T.A (y CENSUS TRACT <br /> i <br /> Owner's Name _�� Phone <br /> 'ddress �` C) f City [_ 1AVDe-IV <br /> Contractor'n Name License / ) CMZ Phone <br /> TYPE OF WORK (Check): NEW WELT. f7 DEEPEN /7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /-J PUMP REPAIR /7 PMV REPIACEKENT <br /> -her <br /> DISTANCE TO NEAREST: SEPTIC TANK /5 SEWER LINES PIT PRIVY / +`�-- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER {' <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELT. Z: <br /> . , PUBLIC DOMESTIC WELL- _ i <br /> INTENDEDUSE r OF WELL CONSTRUCTION SPECIFICATIONS \1 ; <br /> Industrial Cable Tool Dia. of Well Excavation �11! <br /> _ Domestic/private Drilled Dia. of Well Casing X ! <br /> Domestic/public Driven Cauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Infornation <br /> Geophysical Surface Seal Installed By: to ,,A ��� <br /> PUMP INSTALLATION: ContractorU! l <br /> 1A4. C <br /> Type of Pump ,NL ( �bLL H.P. �— <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP .REPAIR: /7 State Work Done C <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> e Des ribs 14aterial. and Procedure w, <br /> I hereby agree to comply w,,'t all law, and tegulaions 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 nmtify them before putting the well in use. The above <br /> irfurmation is t7ue to the best of my knowledge ani belief. I WILL CALL FOR A GROUP INSPECTIO <br /> PRIOR TO UTI _A FINAL INSPECTION. <br /> SIGNED E i TITLZ /,-N , <br /> A? kk. <br /> _ DRAW PLOT PLMI ON REVERSE SIDE <br /> _ FOR DEPARZMEIJT USE ONLY <br /> PHASE I <br /> APPT TrATTAN ArrrP'rr" 13v <br />