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f?n-t3 <br /> iAj _rSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr:.O1F CE USE: /11601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z2L_s,YFP <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 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 joagyin. Local Health District. i <br /> 17- <br /> / c p Ir- <br /> JOB ADDRESS/LOCATION �a cc7-� � o r lo. 7Z& T,,APNSUS TRACT <br /> Owner's Name Phone <br /> Address in., lf�lj'A City ' '� { <br /> Contractor's Name License U/ t-Phone <br /> TYPE OF WORM (Check) : NEW WELL / DEEPEN /7 RECONDITION /_f DESTRUCTION f-7 <br /> a <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT 0 <br /> / <br /> Other / � - D j <br /> �r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Dia. of Well. Excavation f <br /> Domestic/private Drilled Dia. of Well Casing <br /> X Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type: of Grout ' <br /> Disposal Other Other Information ' 1 <br /> Geophysical Surface Seal Installed B <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. 3 e <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: State 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 work on a new well, I will furnish the San Joaquin Local Health District <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 aZL <br /> WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO I G AND A FIN INSPECTIO <br /> SIGNED - <br /> W PLOT ON RSE SIDE ' <br /> E ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE' r-- <br /> ADDITIONAL COMMEN41, <br /> P SP CT PAL INSPECTION i <br /> INSPECTION BY MATE �� =�- ,7� INSPECTION BY _ DATE/ <br /> iE H 14 7ta.._ 1_7zt. /n a Or" t <br />