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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1" Telephone ; (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z=& <br /> 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1f,;;?g , <br /> I <br /> �r��f±(..f�v:�`•��+`/�:� (Complete In Triplicate) -z2_t_ r2p�-2f <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 /> j <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> j JOB ADDRESS/LOCATION � s' - CENSUS TRACT - <br /> r� . _ _-.._, _ <br /> IT <br /> Owner's Name /� e — -- Phone 1022- 03 <br /> Address Z1.erj A�7 4 .,1=. 5,...7-i?,ec-i— City 6 411 4 -- <br /> Contractor's Name bt IV,.r i? 5•A.C. 6201-12 1. Qc gg7k f License Phone �3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 'L-- <br /> ""SEWAGEID sOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �� <br /> INTENDED USE TYPE OF WELL r -CONSTRUCTION SPECIFICATIONS <br /> Industrial 'i Cable Tool 'Dia. of Well Excavation <br /> Domestic/private 1. Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> � .. Irrigation 11 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection :i Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical. ; Surface Seal Installed By : <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump Tve2 6i.ti c, H.P. - <br /> PUMP <br /> .P •PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /+ / State Work Done g/0 44IV'-A, <br /> I. DES•TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> t 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 we11;"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 GROUTIN AND A FINAL INSPECTION. <br /> SIGNED _ TITLE,'7 <br /> a (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ICOR DEPARTMENT USE ONLY <br /> PHASE I e <br /> i APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II G OUT INSPECTION PHAS II/F. AL INSPECTION <br /> INSPECTION BY. DATE INSPECTION BY DATE/ofir L'7 7 <br /> 2M <br /> ,�__�E4H_1.426 Rev. - I-74 coo <br />