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.• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0R70FFICE USE: 1601 E: Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `7S--/// <br /> TH ERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ta.--34-74/ <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local-Health District for a permit to construct A <br /> and/or install I 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 .. l. C� /�ie /1 h o '`/r`?,l CENSUS TRACT <br /> Owner's Name �r ��-�,,, n t Vit, Phone 3 r—��7� k, <br /> Address - 7r.a c r l `c� City '_ ! r- <br /> r:,S <br /> Contractor's.Name Dtn1n a License # Phone <br /> TYPE OF WORK (Check): NEW WELL 7 DEEPEN '/7A RECONDITION /_7E <br /> DESTRUCTION <br /> 1 PUMP INSTALLATION -/* / PUMP�R#EPAT Ikt �/ I/�`PUMPj REP ,ACEMN <br /> Other 1_7 — � <br /> K � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , <br /> PROPERTY LINE - PRIVATE DOMESTIC ,&L PUBLIC DOMESTIC WELL 6. <br /> INTENDED USE TYPE OF WELL - "CONSTRUCTION SPECIFICATIONS <br /> Industrial Cab1e_T.001.._-..-_-4-Di.a. of Well,1,Excavation <br /> Domestic/private Drilled Dia, of Well Casing ; <br /> -_ Domestic/public Driven Gauge of Casings <br /> Irrigation Gravel Pack Depth of GroutCSeal tri. <br /> Cathodic Protection Rotary �Tp�e of Grout S _ <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed By: ! r _:r_.. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %/ State WorkjA <br /> Doge <br /> PUMP-.REPAIR: /_7 State Work Dome- <br /> ES•TRUCTION OF WELL: Well Diameter / <br /> . b <br /> Approximate Depth �S� <br /> Describe Material and, Procedure\�. t r?,-e_ 1AD <br /> ic <br /> a w' <br /> I hereby agree to comply with%all l ws and regulations of the San Joaquin Local Health District., <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS, '`:A'_, <br /> after completion of my work on a new well, I will furnish the .San Joaquin Local Health District 4.11 <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in.use.. The above <br /> informatios true to the.best omy knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> n f- <br /> PRIOR TIN FINAL.iNSPE ION. d, <br /> SIGNS TITLE �> <br /> DRAW PLOT PLAN ON REVERSE SIDET �. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �/� <br /> APPLICATION ACCEPTED BY CSa� DATE <br /> ADDITIONAL CO TS: <br /> P S GROUT PEqMP I F N INSP$CTION. 'L> ` <br /> INSPECTION BY ,/ DATE INSPECT I ATE` -- 13 .l <br /> y E H 1426 Rev. 1-74 1-74 2M <br />