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SAN JOAQUIN LOCAL HEATH DISTRICT <br />Foo. OFFICE USE: 1601 E. Razelton Ave . , Stockton, Calif. <br />`. Telephone: (209) 466-678.1 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� /.�•�� <br />THIS PERMIT EXPIRES I YEAR FROVI' DATE ISSUED Date Issued <br />l (Complete In Triplicate) 2-4-= <br />sppiication is hereby made to the Sean Joaquin Local Health District fo.w a permit to construct <br />Ind/or install the work herein described. This application is made in compliance with San Joaquiti <br />;ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br />'OB ADDRESS/LOCATION �� ,> ?� CENSUS TRACT <br />77M I .........�.........�. <br />per's Name <br />Adreas <br />:ontractor' Es Name <br />X92771: <br />r,;-16 <br />Phone <br />Cityc. c_ ' L <br />License } Phoneme.:,! <br />iy <br />`YPE OF WORK (Check): NEW WELL / DEEPEN I-7 RECONDITION /-7 DESTRUCTION /7 <br />PUMP INST LATION / 7 —PUMP REPAIR / PU14P RE ILACMW *jg <br />Other L1 <br />sISTANCE TO NEAREST: SEPTIC TANK /+ o SEWER LINES IM -1 PIT PRIVY <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PI'." OTHERISVP <br />PROPERTY LIMP - PRTVATP Y)nVV1Q1rTr% tip". PITRT TO rdn%nac�rTr» WV1.7 <br />industrial Cable Tool <br />ilia. of Well Excava1.10n " t <br />Domestic/privat+eDrilled <br />Dia. of Well Casing "._. <br />Domestic/public+ Driven <br />Gauge of Casing /,P-. <br />Irrigation 3 Gravel Pack <br />Depth of Grout Seal <br />Cathodic Protsection <br />.. tel Rota ry,...-_. _ ,. <br />.,. r.Type _bf .. Grout.�?Lt& <br />Disposal s Other f <br />Other Information <br />Geophysical <br />Surface Seal, Installed By: '- } <br />'�a"f"J' <br />INSTALLATIONz Contractor <br />Type of Pump <br />} <br />tit ' .... r <br />'UST REPLACEMENT. F7 State %fork. Bone <br />;1', <br />`UAiP '. PAIR: �-7 State Work Done <br />.. , <br />-,Depth <br />ESTRUCTION OF WELL; Well Diameter <br />Approximate <br />Describe Material and Procedurei7 <br />ti <br />hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />nd the State of California pertaining to or regulating <br />well construct..on. Within FIFTEEN DAYS' <br />fter completion of my work on a new well, I will <br />furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the tell and rio tify thaeii bef6ii putting "the . we�.l ".in . use... The above <br />nformation is true to the best of my knowledge <br />and belief. I WILL CAIL FOR A GROUT INSPECTION <br />RIOR TO rROUTING AND INALIN ECTI �7. <br />c <br />IG;vED % <br />TITLE 77 <br />LI1LE r �Y✓ i <br />D PLOT <br />.LAN' ON REV RSE SIDE <br />R DEPARTMENT USE ONLY <br />EASE i <br />_ <br />.P :ATION ACCEPTED BY <br />DATE' � <br />.LL__ IONA.L COMMENTS. t <br />PRASE II GROUT INSPF:GTION <br />PHASE II4; FINAL,_ INSPECTION <br />NSPECTION BY HATS "'2+f'►- <br />_ <br />INSPECTION BY �. DATE{ & `11--2 <br />R 1426 , .. �. <br />LI75 2M <br />