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t Cb*1 SAN JOLOCAL HEALTH DISTRICT <br /> � Ia AQIIIN <br /> FOE OFFICE US : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> IM APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-/0 7-S10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I� ,q�/ (Complete In Triplicate) 0PS /-S -Of <br /> App cation 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 Frith San Joaquin <br /> County Ordinari�ce No. 1862 and the "Rules and Regulations of the San Joaquin Local Health District. <br /> s,JJa rid <br /> 2- <br /> JOB ADDRESS/LOCATION �Dp ' /II /a ee � � 9 CENSUS TRACT <br /> s <br /> � Phone <br /> Owner's Name &4 '' <br /> Address I Be 6 N / p 9 .b City <br /> Phone '-7 <br /> License # �' <br /> Contractor's Name v�d�� °� <br />� I a <br /> i <br /> I <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN <br /> AL '/ ./ PRECONDITION /_/ DESTRUCTION / <br /> PUMP INSTLATION I I <PUMP REPAIR LX PUMP REPLACEMENT /7 -4) <br /> Other <br /> If <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 I <br /> rZ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> rivate Drilled Dia. of Well Casing <br /> Domestic/p� Driven Gauge of Casing W Domestic/public _ <br /> YP <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodi <br /> ,Mc Protectioxi Rotary Type of Grout <br /> Other Informon <br /> ati <br /> Disposal Other " <br /> Surface Seal Installed B ! "fl <br /> Geophysical <br /> `� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> , • e Work Done <br /> PUMP REPLACEMENT: . / / Stat ; <br /> PUMP .REPAIR: I / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> it Describe Material and Procedure <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 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 .•z <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true to the besttaf-my owledge axed belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FI CT <br /> TITLE <br /> SIGNS <br /> �k PLAN 'ON LRSE SIDE) ; <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y DATE/j9 72- G _ <br /> APPLICATION :ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> 1� PHASE if GROUT INSPECTION t DATE �!� :12. 76, <br /> INSPECTION BY DATE INSPECTION BY ' <br /> 3/76 2M <br /> E H 14260 Rev. 1--74 <br />