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rro SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO FFZCE U,SE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> a <br /> Te IE : (2049) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 <br /> THIS .PERMIT EXPIRES 1 YEAR FROMDATEISSUED Date Issued � Z <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 andithe Rules and Regulations of the San Joaquin Local. Health District. # <br /> JOB ADDRESS/LOCATION v2-0 3WAl. A4 <br /> e ,1/VLljeCar 7D. E CENSUS .TRACT <br /> Owner's Name Phone 7� Y. 4 -S 1 <br /> Address -PO p --- ,1;� <br /> �A/ Z2 City / <br /> Contractor's Name <br /> JYiI� ` -4 <br /> +� j > Licen-se #1"O F,Rhone <br /> ftTo a0K -f <br /> TYPE-OFZWORKK-(Check-)-:- NEW WELL, _=DEEPEN RECONDITION f ../ ,DESTRUCTION--/�±�- :. <br /> PUMP INSTALLATION•-/Z/`--PUMP REPAIR / / YEUMP: REPLACEMENT /� � y <br /> -.. ,.Other'`/_::: max -; <br /> DISTANCE TO NEAREST SEPTIC TANK44W SEWER LINES Ip 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 <br /> Industrial A Cable Tool. Dia, of Well Excavation ``�%'•��JPS''�' �® � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public k Driven Gauge of Casing ' ? <br /> Irrigation Gravel Pack Depth of Grout Seal A. <br /> Cathodic Protection Rotary Type of Grout /Z-Wr4&- M 5A <br /> Disposal Other Other Information Ilk <br /> Geophysical ' # y Surface Seal Installed_ By: <br /> --- 1 <br /> R ' <br /> PUMP INSTALLATION Contractor . <br /> Type of Pump \ <br /> PUMP REPLACEMENT: <br /> � / / State Work Done <br /> PUMP REPAIR: } / / State Work Done <br /> DE-S�TRUCTI ��ONOF WELL•: Well Diameter ` - <br /> . Describe Maters nd Procedure , <br /> I hereby agree toycomply with all laws and regulations of,the San Joaquin La Health Distric d <br /> and the State of Cad iforniaYpertainaiig-to -or.. regulatin-g Q611't'cons t`ruction. "Within-FIFTEEN`DAYS <br /> after, completion of my work on' a new well, I will furnish the San Joaquin Local Health District,:-a.0 <br /> WELL DRILLERS REPORTfo,f the well. and notify them before putting- the well in use. The above <br /> I' <br /> information is "t"rueTom? to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTINGA F N L NSPECTION. <br /> SIGNED D TITLE <br /> t ; i .. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .; -DATE .G -7 { <br /> ADDITIONAL_COMMEN.TS: .�.�___ <br /> f <br /> PHASE II GROUT INSPECTION' } 4 PHASE, II/FINAL INSPECTION p <br /> INSPECTION BY: �. .. DATE' _ �. �'. ", A� <br /> 7 "" INSPr,CTION'BX'�`" "` —DATE 7-.''-7 - <br /> e <br /> 07.7 2M <br /> E H 1426 Rev, • 1--74r _ _ !f <br />