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6 X <br /> '+ ✓ SAN JOAQUIN LOCAL :HEALTH DISTRICT mm_----- <br /> FOPi!OFFICE. USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3,1,74-1 <br /> S- <br /> j z_�� <br /> THIS PERMIT EXPIRES 1 YEARFROM 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 instar, the work herein described. This application is made in compliance with San Joaquin <br /> CountyrOrdinance No. 1862, and the Rules and Regulations of the San Joaquin Local. Health District. <br /> .TOB ADDRESS/LOCATION o � � jV%fterA4 AMA <br /> CENSUS TRACT lg <br /> 3- 70-Y23 <br /> Owner's Name � - <br /> # Phone _�1cs yLl 3 , <br /> Address ndi <br /> }} City <br /> .Contractor's Name f License <br /> � ��t,/Phone \ N <br /> TYP$ OF WORK (Check). NEW WELL�� DEEPEN /_ ~RECONDITION /— DESTRUCTION /7 ' <br /> PUMP INST LATION / / PUMP REPAIR /? PUMP REPLACEMENT f <br /> Other'/-7 _ <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY <br /> 77 � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER _ <br /> INDED {TSE PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> TENTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _� Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing i� L <br /> Domestic/public c Driven Gauge of Casing �C <br /> Irrigation �f Gravel Pack Depth of Grout Seal <br /> Cathodic Protection # RotaryY��— Type-og Grout- <br /> Other Information' ' <br /> ---- - <br /> Disposal ? (Other4 <br /> .- f <br /> Geo h $iTcal t <br /> " ��y Surface Seal Installed B <br /> PUMP INSTALLATION: ' <br /> Contractor �� q •� V �- - <br /> �}��*� Type of Pump! _ u <br /> p � ' � i tl �•P <br /> PUMP REPLACEMENT: E7 'State Work Done g '� <br /> ------------- <br /> PUMP:REPAIR: / / State Work Done <br /> ES; ?,UCTION OF WELL: Well Diameter `+.. <br /> De4cribe Material.and Procedure Approximate Depth <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 regulatingWithin FIFTEEN DAYS <br /> well construction. <br /> after completion/of my work on a new well, I will €urnish the San Joaquin Local Health District $ <br /> WELL DRILLERS RLPORT,'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 i <br /> PRIOR TO GROUTING AND A FINAL 4NSPEGTION. <br /> SIGNED- <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE II R . ARTMEN USE ONLY J <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: cr . ,. / I <br /> PHASE II GROUT INSPECTION ; PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B <br /> ---— DATE27-77-711 <br /> 'E H 142_6___ ` <br /> Rev. ].-74 <br />