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YSAN JOAQUIN LOCAL-HEALTH DISTRICT '�j� <br /> F0 . OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-SD5 u� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -5-- <br /> (Complete <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. 1462 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /d8 o �• - - _ CENSUS TRACT ' <br /> +' Owner's Name ley Aloye. kl— Phone y rte. 7ZZ <br /> Address 1 �.� w r ! ©�� J r o City <br /> Contractor's Name �! License # ,Qqo,!�8 Phones4 41142 <br /> TYPE OF WORK (Check) : NEW WELL /�/, a DEEPENS/_% RECONDITION %_% ;DE5TRUCTT6N '/-7 \� <br /> ` PUMP INSTALLATION /. /; PUMP REPAIR / / PUMP REPLACEMENT /- V <br /> Other, / / z <br /> DISTANCE TO NEAREST: SEPTIC TANKA � ER'. LINES yQ aaW4?IT PRIVY <br /> w. <br /> SEWAGE DISPOSAL F LD », 4. CESSPOOL/SEEPAGE PIT OTHER <br /> ` PROPERTY LINE- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL , <br /> INTENDED USE ,'TYPE OF WELLN CONSTRUCTION SPECIFICATIONS , <br /> M <br /> Industrial 1 CablelTool ` Dia. of Well Excavation /a" <br /> r Domestic/private Drilled Dia. of Well Casing <br /> r F Domestic/public 1 Driven F Gauge of Casing Alcot.0 <br /> { t Irrigation I Gravel Pack t Depth of Grout Seal , 7-/. <br /> f Cathodic Protection _ Rotary Type of Groutl <br /> 'Disposal'DisP Other Other Information Gr2 <br /> _ <br /> ./1p/i: .�-�� <br /> _.., ,Geophysical _ Surface Seal Installed B - <br /> PUMP 'INSTALLATION: Contractor <br /> Z-Type of PumpH. <br /> e' P. <br /> F <br /> a' <br /> PUMP REPLACEMENT: / / State Work Done ► <br /> PUMP .REPAIR: / / State Work Done <br /> //10 IC t <br /> DES•TRUCTION-OF WELL: Well}Diameter Approximate Depth <br /> ''"'�,,._.�------•�Dtscrbe Material and P ocedure <br /> I ierpby agree to c.amply with. all- laws . " d' regulations of the ,San.Joaquin Local ealth 'District <br /> and the�ls4flite_"0007_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 'GWYTIW _AND A FINAL INSPECTION. <br /> �IGNED' .r.� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) , t <br /> F• DEPARTMEN ,VSE ONLY <br /> 7PHASE I C } <br /> APPLICATION ACCEPTED BY! DAT ,S� p <br /> ADDITIONAL COMMENTS: <br /> P II G UT INSPECTION S III/ INAL INSPECTION <br /> 'INSPECTION B DATE 2 INSPECTION DATE <br /> '-/ .x2./1 ' . - � r x I d � � . 1/77 _ -2H <br /> 1 E H 1426 Rev. 1-74 �!/� AL fx�m.,1 - r <br />