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Y, <br /> ` - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. y�yt�+ '. <br /> Telephone: (209) 466-6781 fie'/I 0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is her by 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 '3 s , CENSUS TRACT <br /> CGCG{ a6 6Gr1r+f4 " <br /> Owner's Nameaa S �,// •�L+.•a1 .-. _.._._. Phone S 9 9-3 b r <br /> i <br /> Address .-f ��,L� City <br /> 12 <br /> Contractor's Name S (2-5 a License #J, 3 Phone 4:3 2 -13;PF <br /> li <br /> A <br /> TYPE OF WORK (Check) : NEW WELL /✓� DEEPEN '/ / RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP: INSTLATION/�_PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES t PIT PRIVY <br /> SEWAGE DISPOSAL FIELD yecla CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLY4a:�*PUBLIC DOMESTIC WELL P-ei. � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ^ Drilled Dia. of Well Casing 11 � <br /> Domestic/public Driven Gauge of Casing % <br /> Irrigationy Gravel Pack Depth of Grout Sealfie., -e <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor S'r k3afs,r.t Q}• /fr-. <br /> Type of Pump -- - H.P. <br /> , <br /> a M 3 <br /> PUMP REPLACEMENT /-7 State Work Done <br /> PUMP .REPAIR: / / .State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> ,pd 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 tzue 'to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANjjA FINAL INSPECTION. <br /> ZIGNED I TITLE d�t/ltti <br /> (DRAW I'I,'T PLAN ON REVERSE SIDE} <br /> FO D TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /7,V4-> <br /> A?DITIONAL COMMENTS: <br /> t� <br /> PHASE II GROUT INSPECTION ' PH4SEAV/FIN4 INSPECTION <br /> It,' <br /> PECTION BY DATE ir/ <br />' is t.���N�S�P'7ECTION BY i DATE <br />� _1426 RPu- 1-74 (W�7-6 2M <br /> 7r�_ <br />