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�Y3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: " <br /> 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 746-p?,eA4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued S`:J37d <br /> (Complete In Triplicate) 00?.-'3YO- a�, <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 /> .TOB ADDRESS/LOCATION l� CENSUS TRACT r <br /> Owner's Name44&-' 04z L; Phone <br /> Address <br /> ..< City Q <br /> Contractor's Name ` License s �Phong _ l <br /> i <br /> TYPE OF WORK (Check): NEW WELL /47 -D'EEPL?N /?' RECONDITION /4 DESTRUCTION J j <br /> /? <br /> PUMP INSTALLATION /L IMP REPAIRPUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TONEAREST• . :SEPTIC'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE 'PIT OTH <br /> PROPERTY LINE �- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTEDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> A�d'66trial Cable Tool Dia. of Well Excavation' <br /> ®estic/private Drilled Dia. of Well Casing <br /> Domestic �-�- �`� <br /> /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 /> Geophysical4. 4 <br /> Surface Seal Installed Bv• _. <br /> PUMP INSTALLATIONS Contractor Q . <br /> Type of Pump ' H.P. AFZ <br /> PUMP REPLACEMENTf•y /% State Work Done , <br /> PUMP 'REPAIR: " /-7 State Work Done , <br /> DESTRUCTION OF WELL: <br /> Well Diameter Aproximate Depth- <br /> Describe Material and Procedure <br /> I hereby agree: to ,comply with all laws and regulations of the Sn Joaquin Local__ikga .t'h District <br /> and the State 'of California pertaining to or regulating well"co�istructiari. :WJ;thin--FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joa.4Wc� �$eal.th District a <br /> WELL DRILLERS REPORT rof the well and notify them before putting. the..wel1.in,-u e... -The above <br /> information is true .to the-best-of my knowledge and belief. I WILL CALL `F0t` A GROUT INSPECTION <br /> PRIOR TO..2WW AND, A FMAL INSPECTION. o-- —2J <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � - , <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION . PHASE III FINAL INSPECTION <br /> INSPECTION BY C f'z DATE INSPECTION BYC�3 DATE 2 �•d/6r <br /> ;H 142.6 Rev. 1-74 <br />