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Cf SAN JOAQUIN nrMALTH DISTRICT. 3 <br /> 70 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466-6781 <br /> A'PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 33 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued /�76 <br /> (Complete InTriplicate) <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. 1/862 and(t�h}e Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f�' 31/E� . - �ENSUS TRACT <br /> ate <br /> Owner's. Name. _ Phone , <br /> Address I /9/ 'I f /r7�.1 o fl� `LSC-GtC�l _ -• -- city <br /> i <br /> Contractor's Name License # " hone <br /> M 7 L. <br /> TYPE OF WORK (Check): NEW WELL . DEEPEN /_7 RECONDITION f7 DESTRUCTION fT <br /> PUMP INSTALLATION/ / PUMP REPAIR-/-7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ! <br /> 4 PROPERTY LINE - PRIVATE', DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ] <br /> Industrial i Cable Tool Dia. of Well Excavation _- <br /> Domestic/private ;1 Drilled Dia. of Well Casing <br /> { Domestic/public Driven Gauge of Casing - u <br /> Irrigation ' Gravel Pack Depth of Grout Seal <br /> Cathodic Protection � Rotary Type of `Grout <br /> Disposal Other Other Information." MJ <br /> . <br /> r Geophysical ��,ll Surface Seal Installed' B <br /> PUMP INSTALLATION Contrae4or <br /> Type o f. Pump H.P. <br />, PUMP REPLACEMENT: . / / State Work Done , <br /> PUMP...REFAIR: --/-7,s.ta-te --Work--Done <br /> DESTRUCTION 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 District <br /> and the State of California pertaining- to' or regulating well'-construction.. Within FIFTEEN DAYS. <br /> after completion of MY <br /> ' work 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 /> li_nformation is true to- thst of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> !PRIOR TOG UTING�AND 1 I SPECT N. <br /> � S;IGNEDG1 TITLE <br /> -7 zda <br /> DRAW PLOT PLAN ON ERSE SIDEI 42 <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I <br /> APPLICATION' ACCEPTED BY DATE %Zfp-7 <br /> ADDITIONAL COMMENTS: <br /> { PHASE II GROUT INSPECTION PHASE' FIN " INSPECTION <br /> INSPECTION BY DATE. 7 INSPECTION BY DATE. -�4'-'Z7 <br /> :5 �r �4-fir d �gd�t✓vi <br /> ,.E H 1426 Rev. 1-74 ✓s� ? _ 2M <br />