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t _ <br /> SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOF•.OFPICE USE: ' 1601_ E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z?�6/f[rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Is$ne4 <br /> (Complete In Triplicate) <br /> Application is 4ereby-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 acid the Rules and Regulations of the San Joaquin Local Health Distr�et. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> r � , �./ f• <br />[ Owner's NameY-el ,� � SU(�//t �q►�? <br /> Phone 'r` <br /> Address. . 3 �-S 7 <br /> City �, j' <br /> r <br /> Contract r s Name h ,/ License Phone Ij <br /> a <br /> TYPE 'OF WORE (Check): NEW WELL-DEEPEN-f-/ RECONDITION /? DESTRUCTION / 7 <br /> PUMP INSTALLATION / / PUMP REPAIR J PUMP REPLACEMENT /_7 <br /> Other /J <br /> N EST _SEPTIC sTANg��" �L SEWER LINES : 'PIT-PRIVY_11���------� <br /> - TW <br /> - --•----�--�--•�-SEWAGE DISPOSAL FIELD f CESSP L/SEEPAGE PIT' OTHER <br /> 0 <br /> PROPERTY LINE.- PRIVATE DOMESTIC WELT: __ PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRIICTION„SPECIFICATIONS <br /> Industrial Cable <br /> Tool, , , Dia: of j.Well 'Excavation <br /> srivate <br /> Dometic <br /> f, /p Drilled „ Dia, of1Well� sinN <br /> �Domestic/public TDriven -`-Gauge of-Casing <br /> ,Ikk7igation Gravel Pack Depth of Gr �, <br /> Grout Seal <br /> Cathodic Protection Rotary a.,; -Type of Grout <br /> Disposal OtherP��.�n _ <br /> `",Other Information r � _.�/r,�.1� �� 0>• � <br /> `,Geophysical `' <br /> Surface Seal:Installed, y: f i l/sar . <br /> PUMP INSTALLATION: Contractor <br /> e of Pump <br /> mp H . - <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP - PAIR: / / State Work Done ' <br /> DESTRITCTION 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 istriet ` <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 San Joaquin Local Health District a k <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-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED _GROUTING ANA FINAL N.INSPECTIO <br /> PRIOR TO- D; � ! 4 - <br /> - _ TITU <br /> PID - <br /> c� _DEA/1ATMNT USE �Z-9-77 �,u- <br /> P - _ _ <br /> - - <br /> ADDITI COMMS; . <br /> PSS GROUT I <br /> NY <br /> -, <br /> n - <br /> W INSPECTIONDA <br /> E h •1426 Rev. 1-74 �6tt-/” <br />