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237 (0 <br /> t—tv, I � - SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27— <br /> J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 351.7 Louise "Ave. <br /> CENSUS TRACT <br /> Owne'r's Name <br /> Mr. ` & Mrs.- Latrell Crosby Phone _ <br /> P <br /> Address 1 Louise Ave." City m +aaa <br /> License # Phone " <br /> Contractor s Name self <br /> + .�-,n.. , _-� _ �-..:. ;. per,. • �- -�� . ' . . <br /> TYPE OF WORK (Check)-: NEW WELL/ / DEEPEN "/ I RECONDITION /_7 DESTRUCTION /7 .� <br /> PUMP INSTALLATION 2 PUMP REPAIR/ / PUMP REPLACEMENT Q j <br /> Other /_ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE.-PITS OTHER <br /> k <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION--SPECIFICATIONS <br /> Industrial _Cable-Tool '-- DiA.-of -Well. Excavation � <br /> Domestic/Rrivate Drilled Dia. of Well Casing <br /> Domestic/public . Driven Gauge of Casing i <br /> Irrigation Gravel Pack Deptli of Grout wSeal <br /> Cathodic Protection Rotary Type of Grout E <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed By: <br /> , . <br /> PUMP INSTALLATION: Contractor se if <br /> TYPE of Pump , H.P. <br /> PUMP REPLACEMENT: State Work Done Replaced 1 I/2 E. Jeb um withal H.P <br /> . submersible pump. <br /> PUMP .REPAIR• / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> r <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 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 /> ` information is true to the best of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> } PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRP 'T`PLAN 'ON RE <br /> AW FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 7 <br /> TION ACCEPTED` BY:'4SPECTION <br /> APPLICATION <br /> ADDITIONAL COMMENTS: <br /> PHASE II GPHAS I I/FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> k <br /> 3/76 2M <br /> E H 1426 Rev. 1-74"' - <br />