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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone : (209) 466-6781 �J� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.27_ ?L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued6__.Z _;7 <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 and 'the Rules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �®2.2, 140 L-0 V Q,T 14 _ --_ - --_ CENSUS TRACT <br /> Owner's Name _d H'O ( Q Phone <br /> Address 90 2-2— ,), # Imo'/L.. o r e-'/- City •�1��V[ <br /> ^ � r �• Phone r� <br /> Contractor's Name L License #TG 6a 4 G� 1 <br /> TYPE OF WORK (Check) : NEW WELL,/1iJ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> ` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /B l SEWER.. LINES _100 t PIT PRIVY <br /> SEWAGE DISPOSAL,FIELD'/&b' CESSPOOL/� EP GE'PIT p--- OT'HER� <br /> —P <br /> .�' PROPERTY LINERIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL (� <br /> INTENDED USE ! TYPE OF WELL �CQNSTRUCTION -SP-ECIFI ATION 1 <br /> --/XR ial Cable Tool Dia. of Well Excavation <br /> Domestic/p�`ivate Drilled , Dia. of Welr'Casirigef aw. I <br /> Domestic/public; r .: Driven Gauge of Casing <br /> Irrigation , A Gravel Pack ,�`�`"` Uepth of Grout Seal i T � <br /> Cathodic Pro-teTc•t on R0taryl Type of Grout -,' Cp� <br /> Disposal rOther,, t Other'„Information Q <br /> Geophysical Wt' + ( Surface Seal Installed By: k <br /> PUMP INSTALLATION: Contractor <br /> # <br /> Type 7 of Pump ►.. H.P. <br /> PUMP REPLACEMENT,:� / / S tats Nork-,Done <br /> PUMP .REPAIR:Ct ?� ( ` /i /� ate�Work-Done,�F; } _ V �' F;. tif, .i <br /> DESJRUCTIO_N OF WELL: ,Well� Diameter} te.s`iK,4 ..l Approximate Depth <br /> Describe Materialwarid ProcedureA"-• t <br /> I hereby agree to comply with all laws and 'regalations of the San Joaquin Local Health District <br /> and the State of California pertaining to or re`gulating �well 'canstruction.r Within FIFTEEN DAYS <br /> after completion of my work on a new well, I• will furnish° ;the Saiz Joaquin Local Health District a <br /> WELL DRILLERS-REPORT of the well and notify them before putting the- well in use. ' The above <br /> informatis true �to. the�best of. my knowledge and belief. I WILL CALL FOR A -GR6UT 'INSPECTION <br /> PRIOR TO 'G OU I GRAN F AL 11. SPECTTON. <br /> SIGNED + TITLE <br /> j --(DRAW,'PLOT PLAN ON REVERSEJSIDE) r <br /> FOR DEPARTMENT USE ONLY �--• " <br /> PHASE F <br /> APPLICATION ACCEPTED",$Y DATE LO <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II/ AL INSPECTION <br />' INSPECTION BY INSPECTION BY DATE 1 , <br /> 7- i <br /> P u IA9A De 1_711. X77 2M <br />