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,. 0 , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFt USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> <. Telephone: (209) 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3L_7,7S 16 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date. Issued F-13- <br /> (Complete In. Triplicate) i S3-6fC,D_. OI <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 Sart Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1'r C�G� / l - . CENSUS TRACT <br /> t <br /> t Owner's Name � �_ � _!�` _- ._ Phone <br /> Address City . . <br /> Contractor's Name <br /> License frhoine - <br /> rZ <br /> - <br /> TYPE OF WORK (Check): NEW WELL ,/_7 DEEPEN '/-7 RECONDITION �T DESTRUCTION' f7 <br /> PUMPJINSTALLATION /� PUMP REPAIR -7 , PUMP REPLACEMENT /? <br /> Other /% i . <br /> E o <br /> DISTANCE TO NEAREST: SEPTIC -TANK SEWER LINES PIT PRIVY o <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'PIT OTHER (r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ' Irrigation Gravel Pack Depth of Grout Seal <br /> { Cathodic Protection Rotary Type of Grout <br /> Disposal ; Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump 77Z 14aAa` H.P. _p . . <br /> PUMP REPLACEMENT: �/ / State Work"Dane <br /> PUMP '.REPAIR: t ,State Work Dane <br /> DESTRUCTION -OF WELL: ''Wal Diameter. Approximate Depth <br /> .Desc'ribe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> anal the.State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my workY 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 true to the,best.of. my-knowledg d belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO qAQTING 'ANDA FINAL INSPECT N. <br /> SIGNED - _ , TITLE' <br /> (1 1� W PLOT LAN ON RUVERSE SIDE <br /> R DEPARTMENT USE :ONLY <br /> PHASE z <br /> I APPLICATION ACCEPTED BY DATE f/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUZ IN ECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 'INSPECTION BY DATE -f Z <br /> ,4 <br /> F. <br /> E R 1426 Ra-u_ i_24 r' _ 75-. 2m <br />