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/tial <br /> "-low <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> ���¢ a P {�- <br /> FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Fleriftit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued Z <br /> ~�7 ' (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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L G 1</A CENSUS TRACT <br /> i <br /> Owner's Name oZ, O Vr /L4U'e,1/ ` K /L�---- Phone <br /> AddressaA✓ G' G City if Al <br /> _.. <br /> �/!� /�i�O _ aa <br /> Contractor's Name 1' License �0� Phone <br /> ""DEEPEN RECONDITION DESTRUCTION _ <br /> TYPE OF WORK (Check) : NEW WELL DEE E / / N N / / I�T <br /> 5' = PUMP FINS ALLA'IION /�j- ( PUMP REPAIR / / PUMP REPLACEMENT / <br /> 0 the-r <br /> I c 4 ' <br /> .DISTANCE TO NEAREST: SEPTIC TANK /OD SEWER LINES le o/-p4 PIT PRIVY y -- --- -- � <br /> SEWAGE DISPOSAL FIELD/6,C�Vgy/ CESSPOOL/SEEPAGE PIT ,1 OTHER _ V <br /> PROPERTY LINE -' PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> ` . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial . . Cable Tool, Dia. of Well Excavation r _ <br /> t/ <br /> X Domestic/private l Drilled Dia. of Well Casing _ZU i, -C.a <br /> Domestic/public. 'wl Driven Gauge of Casing A9 / <br /> Irrigation 6 Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> i Geophysical {�7ntYLQ/L Surface Seal Installed By: <br /> PUMA INSTALLATION: Contractor <br /> f Type. of Pump "` , • H.P. <br /> �b <br /> PUMP ,REPLACEMENT: / /-I'State Work Done <br /> PUMP MEA111. / / State WoTk_-Done—i `pit <br /> .- DESTRUCTION OF WELL: Well DiAmeterTT b �; _ Approximate Depth Q , <br /> 4 Des c.ibe4 Material`and-TF'rbcedure..- b ,LG 6i/X ,� l Jr <br /> � ' ; <br /> I hereby agree to comply with all laws� arid regulations of the San Joaquin Local Health__District <br /> and the State of California pertaining tour re`gulatz}gre �- tion, it inn FF1 'T `EN'�1}AYS ° <br /> after completion of my work on a ne`w­-wei3:- 'T wTl 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 /> i information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A F INSPECTION.v `:E <br /> SIGNED s TITLE <br /> 1' (DRAW ,PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ' ADDITIONAL COMMENTS: It <br /> PHASE II GROUTIINSPECTION PHASE_I.ZI/FINAL INSPECTION <br /> INSPECTION BY DATE 117-7-74,J k IINSPECTION BY DATE J rZ <br /> f Gtow <br />