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SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> r FOIA' OFFICE USE: 1601 E. Hazelton .Ave:, °Stockton, Calif. �? <br /> Telephone: , .`(209) 466-.6781 <br /> w APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. 75--//-1�1-J <br /> ¢. THIS:PERMIT. EXPIRES 1 YEAR FROM.DATE .ISSUEDDate`Issue %/-7S� <br /> ' . . ::r tt46 .. � Y . .<, � .�(Complete.In Tr.ip�icate) . ; : -E:: .f^, 4� <br /> Application is hereby made 'to the San Joaquin -Local. Health Via trict: for 'a permit-to-construct <br /> and/or install. the,work herein described. This ,application is ade� in-compliance with San Joaquin <br /> County Ordinance No..,1862,�'and. the..R.ules ,and.Regulations .ofi.�:ihe -San`Joaquin-Local Health Dfsttict. <br /> JOB ADDRESS/LOCATION. <br /> CEN$US"TRACT 0S1 21_ 05 <br /> _,. <br /> -a . <br /> Owner's Name f. -a _. Phone <br /> Address - _ x=.. v CVity.. . x <br /> �t .., .,,��, <br /> Contractor's Name ` License Phonet„ <br /> TYPE OF WORK. (Check) NEW WELL /5DEEPEN / . RECONDITION+/� DESTRUCTION � T - <br /> i y t 5 PUMP>INSTAI:LATION /cif'PUMP REPAIR PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK MSEWER' LINES PIT PRIVY <br /> : SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT; OTHER <br /> PROPERTY LINE <br /> -PRIVATE DOMESTIC WELL PUBLIC.DOMESTIC WELL <br /> j INTENDED USE `TYPE OF WELLp CON STRUCTION, SPECIFICATIONS <br /> Industrial e�C'able To Dia. ;of�Well-Excavation. <br /> `--'V mestic/private t. . .Drilled Dia. of Well Casing ,? <br /> Domestic/public' Driven i Gauge o€. Casing r / „ . .„ <br /> Iriigatian :.Gravel Pack Depth of Grout Seal ' .� "f <br /> 4 a <br /> ' Cathodic Protectiorj - - Rotary a of Grout <br /> Disposal r I Other Other Information:' <br /> Geophysical Surface Seal Installed B <br /> PUMP IN5TALTaATION:� ? Contactor <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: / ./ State .Work bane <br /> PUMP '.REPAIR: /-7 State Work Done <br /> - ^.r`Y'^`�.�-: -�q�—+ —'—Rs -- .r.� ,. ,rk ,�.- _�Kta�•e„•.. _..y -"Per <br /> E5TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc ibe. Material and Procedure <br /> I Hereby agree to comply with all laws and regulations of--the- San Joaquin Local Health District <br /> and the State of California pertAning to or regulating well constriction. "Within FIFTEEN DAYS : <br /> after completion of my work on anew well,. I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify.them before putting..the..wel1 in-use.. ' The above <br /> information is true to -the best of.: mylknowled$e and belief. I WILL CALL FOR A GROUT 'INSPECTION <br /> PRIOR TO GROYZING,,AND A FIN NSPECTION <br /> SIGNED TITLE <br /> F. DRAW PLOT .PLAN ON REVERSE SIDE)' <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: :. ` t <br /> PHASE II 'GROUT °INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE / ` 7� •` .INSPECTION. BY - DATE -Z.3-75� <br /> �t ° � H 1426 Rev. 1-74 I-74 2M <br />