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___ _ ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT VOL ICE USE: 1601 E. Haselton.Ave., .Stockton, Calif. <br />Telephones .(209)1'466-6781 <br />APPLICATION FOR -WELL CONSTRUCTION OR PUMP PERMIT Permit No. za/L ' <br />t <br />r THIS PERMIT EXPIRES l YUR ELM R&TE ISSUED Date Issued <br />(Cl+et+e in Triplicate) W <br />Application is hereby made to the Sats 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 San Joaquin Local Health District. <br />JOB ADDRESS /LOCATION o - �: --� CENSUS TRACT <br />V <br />4wner'a Name i 'hone ...._ <br />Address --- �/� .Wv.+.� City. <br />Contractor's Name License # '"'`"e <br />TYPE OF WORK (Check): NEW WELL /-T DEEPEN /" RECONDITION /7DESTRUCTION <br />Pump IN&TALLATION jR PUMP REPAIR /7 —pme R,EPLAcnexT . / <br />Other L-7 <br />DiYIAN" a -v a;+s sTs sa rwic <br />Twx 3EWER <br />SEWAGE <br />DISPOS FIELD <br />PRQPZ= <br />L - PUYA, <br />INTENDED USE <br />TYPE OF WELL <br />Industrial <br />Cable Tool <br />Domeatic/private <br />W. Drilled <br />Dowestic/public <br />_.. Driven - <br />Irrigation <br />Gravel Pack <br />Cathodic Protection <br />Rotary <br />{ Disposal _ <br />Other <br />--..—Geophysical <br />PUMP rNSTALLAMM& Contractor <br />Type of Pump <br />Y CESSPOOL/SEEPAGE Y*I— OTHER <br />3TC WELL&PUBLIC JbWTICJ <br />SPECIFICATIONS 'x <br />Dia. of Well Excavation <br />Dia. of Well Caning <br />Gauge of Casing <br />Depth of Grout <br />Type of Grout;` <br />Other Informat on✓ <br />PUMP REPLACEMENT: State. Work Done <br />'mom- WM1lM4 W W�YW..WIWYW/WW.IWIWIWIWlWWIWI11111.1)1 WYI <br />YUMP..R'AiR.._.. .....:. t..t$te Work Diiie,:.sK. h '�-W�:W _ .��Is, .. •.-.-.. ,,..� <br />IYW`' wLil11YY <br />2ES ' MON OF WELL: Well Diameter Approximate Depth <br />7 r Describe Material Za Procadure <br />I hereby agree to comply with all lags and reg tions of the San Joaquin Local Health District <br />and the State of California pertaining to at regulating wall construction. Within FIFTEEN DAYS <br />after completion of my' world 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 puttiing. ths..we .,l in . u".. The above <br />information is true to the'best'of my.knowledge and belief. I WILL CALL FOR'A'GRaOUT INSPECTION <br />PRIOR TO .GRiDt NG AND J( FjNAL,MSPEQa0N. <br />SIGNED <br />?RASE I <br />LICAT-ION ACCEPTED BY <br />._,>JITTONAL COMMENTS: <br />INSPECTION BY <br />'u. <br />' 8aH 1426 Rev. 1.74 <br />i <br />TITLE <br />INSPSCPION <br />