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Lo �o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " FOE OFFS E USE: 1601 E. iiazelton Ave. , Stockton, Calif. <br /> �,,• Telephone: (209) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3141/c <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued S1L-�6 <br /> 43"-?,s (Complete In Triplicate) z 3 � C 30--d3 <br /> Application is hereby made t6 the San Joaquin Local Health District �or <br /> a permit to consttluct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18bI and the Rule and Regulations of the San Joaquin Local Health District. <br /> s <br /> JOB ADDRESS/LOCATIONZj�e_ 7ene. JF,9� IOW CENSUS TRACT I <br /> Owner's Name C4, hO_ X o Phone ' <br /> Address .S/ 40,4p a etep City _,t S4 ®� <br /> .,,may <br /> Contractor's Name *d;r- GGA G License # / hone . 72 7ol <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/-7 RECONDITION -f-7 DESTRUCTION /_7 <br /> W <br /> PUMP INSTALLATION / / PUMP REPAIR 'k� PUMP REPLACEMENT /_7 - <br /> l, Otherl I <br /> :DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES PIT PRIVY' . <br /> SEWAGESDiSPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f�r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �i Cable Tool, Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing. <br /> Domestic/public i Driven Gauge of Casing <br /> _Z Irrigation ,; Gravel Pack Depth of Grout Seal <br /> Cathodic Protection r Rotary Type of Grout <br /> Disposal Other Other Information ' -- �, <br /> Geophysical Surface Seal "Iris tailed 'B <br /> PUMP INSTALLATION: Contractor 4� C& •,. <br /> Type of Pump -� ~' S.P. o <br /> PUMP REPLACEMENT: %/ State Work Done <br /> " PUMP '.REPAIR: State Work Done Z,6 <br /> � DE&TRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure " <br /> 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 well, I will furnish the Sari Joaquin Local Health District .a <br /> WELL DRILLERS REPORT of the well and notify theca before putting.the..well..in.use.. .The above <br /> information is true Co:the-best .o y. know nd belief. I WILL CALL FOR'A'GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL INSP I . t� <br /> SIGNE w ITLE I_Isy <br /> RA PLOT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED ,BY DATE -� <br /> ADDITIONAL CONHENTS: <br /> PHASE II GROUT'I PE ION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H 1G26 gev. l�lk 4 75 <br />