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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J, <br /> THIS PERMIT "EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 and the Rules and Regulations of the San Joaquin Local Health"District. <br /> _ <br /> JOB ADDRESS/LOCATION G5 4/'}A ,. L.A&_� CENSUS TRACT <br /> Owner's Name 1 � -1{C1191WIMA Phone Wv'16 6- <br /> Addressh <br /> J GAI&'Sa AVF. _S;�l2,G,If dl...,._....__ ._..... City <br /> Contractor's Name �^�•� jffA�' //� =} - � License- 1t2j2Q7qy Phone <br /> TYPE OF WORK (Check) : NEW WELL RIT DEEPEN -/_/ RECONDITION /_7 A DESTRUCTION /_7 <br /> PUMP, INSTALLATION 'X PUMP REPAIR/ / . PUMP REPLACEMENT /? <br /> Other / / fA 4 <br /> DISTANCE TO NEAREST: SEPTIC- TANK ,370-' SEWER LINES So 4 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 .1 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool . ,\Di-a.-_of�,Wel1. l Excavation /11 <br /> 4.Domestic/private i Dri1le k Dia: of . Casing (�� ; <br /> Domestic/public I Driven";,O- ---�----- <br /> /p Gauge4-oft Casing <br /> Irrigation 1 Gravel!Pack Depth of. Grout Seal D FT <br /> Cathodic Protection Rotary Type' of Grout S�YNJ� Ers� fuT <br /> —Disposal i Other I ther Information <br /> Geophysical Surface Seal Installed By: IAC <br /> PUMP INSTALLATION: Contractor ' C. <br /> Type of Pump l �F ...,_...,,.. '� ----- — H.P. � <br /> PUMP REPLACEMENT / / State Work Done + <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply withyall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well-construction. Within FIFTEEN DAYS <br /> after completion of my work on a new.well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT 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 <br /> PRIOR TO GR04LTING D 61FINAL.{INSPECTION. 4 <br /> SIGNED 4dzt�'44r TITLE <br /> 77 1} W PL T' PLAN'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY : <br /> PHASE IZ� �Tat, � <br /> APPLICATION ACCEPTED BY _� BATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION-- ... �. `-'- Y - f�{PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE 2' " INSPECTION BY TE tcliK/ <br /> 16� 1 3- 21E H 1426 Rev. .1-74 2M f <br /> _. <br />