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SAN JOAQUIN LOCAL. HEALTR DISTRICT <br /> ' �; � Calif. <br /> FOh OFFICE USE. . 1601 E. Hazelton Ave. Stockton, <br /> Telephone: (209)466-6181 <br /> s- APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No.7 L-4e <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 9 , <br /> (Complete In Triplicate) ' <br /> Application-is -fiereby made tolthe San JoaquThisin oaallgcati n isalth tricmade inrcompl cea permit Cwith San Joaquin <br /> and/or install the work herein described. <br /> PP <br /> County Ordinance No. 1862 and: the Ru ani�Regu a ions of the San Joaquin Lacal Health District.- <br /> 2! 47 .�' ., CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> X-r�ac Phone <br /> Owner's Name + <br /> City <br /> C <br /> Address <br /> icense <br /> Phone <br /> Contractor's Name <br /> a s 5 <br /> RECONDITION_/ / DESTRUCTION /� <br /> TYPE OF WORK (Check) NEW WELL DEEPEN / _ Pt4 REPLACEMENT I- <br /> PUMP INSTALLATION—/ <br /> I PUMP REPAIR / I T <br /> � _ ._ � � �T Other-I_�/� -- �- .�,.....� .._-�-..... �_ .. -•- ra �.' .. <br /> O i a\ ��)j / 1. <br /> DISTANCE TO NEAREST: SEPTIC ff SEWER LINES SPIT PRIVY �IILYt[T5J �4�"' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT R � Q <br /> �, - PUBLIC DOMESTIC WELL <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> ,TYPE OF WELL <br /> ' INTENDED USE _ . Dia. of Well Excavation " p <br /> Industrial Cable Tool Tw9w <br /> Drilled `-Dia. of We`1.1 Casing rivateQ <br /> //- Domestic/p Driven - Gauge of--basing <br /> Domestic/publicO <br /> Gravel Pack `Depth of-Grout Seal <br /> Irrigation Rotary Type of--Grout <br /> Cathodic Protection ' y s--.r <br /> �. Other;Information , <br /> -4 Disposal Other _ Surface 5ealr-I stalled B <br /> -Geophysical .- <br /> PUMP INSTALLATION: Contractor *L H.P. <br /> i Type] of Pump <br /> PUMP REPLACEMENT:,._ / / State Work Done""" <br /> PUMP .REPAIR: / / State Wor:: Done P ' "g:;' I <br /> - . <br /> proximate ep DES-TRUCTION OF WELL: We 1 Diameter <br /> Describe Mater al and Procedure <br /> I hereby agree to comply with all laws odoreregulatingowell-construction.LoWithinHealth <br /> FIFTEENDistrict <br /> DA'YS <br /> and the State of California pertaining t g <br /> aftericompletiOn of my work on a new well, Ithemlbeforesputtingthe athe'well in use.Health <br /> aboveDistrict <br /> WELL DRILLERS-REPORT- of -the-well and notify <br /> information is true to thelbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR9UTING AND X)FIRAL INSPECTION. TITLE <br /> SIGNED ` RAW PLOT PLAN REVERSE SIDE) <br /> FOR DEPART T USE ONLY <br /> PHASE I� DATE 9 7 7 f AP CLP I ATION ACCEPTED BY t <br /> ADDITIONAL COMMENTS: P� /FIN INSPECTIO <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE !U U <br /> A,I ___T_ - A/1' �77 -2M <br /> ou <br /> I n II Y1.hr. Vn 1-74 <br />