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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.Kr <br /> Telephone: (209) 466-6781 ��- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S_ 37GW i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �- 7S' <br /> (Complete In Triplicate). <br /> Application is hereby made totthe 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 /> .TOB ADDRESS/LOCATION ��ct r r� ©r /05-/3 CENSUS TRACT <br /> Owner's Name- E I.�iA l i13 + Sa iv G c k! il)G'TT 1 Phone <br /> n �T z10l�? <br /> Addre s,. V C� t lVGh�1 city 6. J-T._, SL`/ <br /> Con traeor's•_Name, O� Of-t-1- P -tt41 P r_VT License #-76,b67- Phonefj( c` t <br /> TYPE OF WORKCChhe,jk): N WELL / DEEPEN RECONDITION _ DESTRUCTION <br /> INSTALLATION/ / PUMP REPAIR -/-7 PUMP REPLACEMENT %f <br /> `1f1.1er <br /> v .: <br /> DISTANCE TO NEARE T: ySEP�IC TANK SEWER LINES PIT PRIVY �^ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v1 <br /> . PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED US TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /0 <br />_X-- Domestic/pr vase. Drilled Dia. of Well Casing Z " <br /> Dome stic/pub lie Driven Gauge of Casing_ / 2 <br /> Irrigation Graved=flsc�e~-- _.__.. - rou ea -._ .....- .-- _.... <br /> Cathodic Pro tection Rotary Type of Groutnitd <br /> Disposal t� Other Other Information- ' 1 <br /> Geophysical: Surface Seal Installed By: <br /> PUMP INSTALLATION. Contractori, x}21 tL F ul P�`1E,�J L"t1 <br /> Type of Pump &k-8 HE 518 L E H.P. /72- <br /> PUMP <br /> 2-PUMP REPLACEMENT: ` / %tate Work Done i <br /> PUMP ,REPAIR: 1y / / State Work Done " <br /> 17 7t <br /> DESTRUCTION OF WELI Well Diameter L _ Approximate Depth <br /> Describe Material and Procedure . . . . . . . . <br /> I hereby agree totT:..c <br /> ly with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Co7rnia' pertaining to or regulating well "construction. Within FIFTiIEN DAYS <br /> of ter completion o �wor1C_&n a new-�we11, ;I�will furnish the San Joaquin Local Health District a i <br /> WELL DRILLERS.REPOf;the'-,real-mrd-fto ify-them-b�Wfore put_fing fhe. e n.use.... . e a oveinformation isi,tru - the,best of- my..knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GRO GF I SPECT_ ION.'� ') ` ,, :�,:,� <br /> SIGNED r' TITLE 0 X)TR A C-Fd <br /> (DRAW PLOT PLAN ON REVERSE SIDE) >` <br /> OR DEPARTMENT USE ONLY <br /> PHASE 'I <br /> APPLICATION ACCEP'.LEDDATE 1 <br /> ADDITIONAL COMMENTS.: t <br /> p ASE > OUT INSPECTION PHASEIII FINAL INSPECTION <br /> INSPECTION BY DATE /p/ 1-7 f INSPECTION BY t-1V DATES_ ;_7,�_ <br /> E H 1426 liev. 1-74 h/75 2M � i <br />