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SAN JOAQUIN LOCAL. HEALTH DISTRICT w <br /> 4FOR.','OFFICE USE 1601 E. Hazelton Ave. , ,Stockton,, Calif. T ` <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No.YVI <br /> �- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ►, I <br /> Application is hereby made (Complete In Triplicate) <br /> 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. vrith .San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ?2,3 -1Mf CIA" ffX C NSUS TRACT <br /> Owners Nacre -- one UOZ 3- 157-3/3- <br /> Ad dress <br /> -Address .2 -.5. City � Q <br /> a <br /> Contractor's Name Y,( /7n -f',. <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/—/ RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION./ / PUMP REPAIR /-7 PUMP REPLACEMENT /? <br /> Other 1/ / q <br /> DISTANCE TO NEAREST: SEPTIC ,TANK �♦ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /FDS CESSPOOL/SEEPAGE PIT OTHERfeU- 91>� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC'DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - � Rotary Type of GroutAm <br /> Disposal Other Other Information' ? <br /> Geophysical Surface Seal Installed B : <br /> ti <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: / / State Work Done � w ! <br /> P / State Work Done <br /> ��a �� o 4 <br /> DESTRUCTION OF W LL: Well Diameter f ,. AppATmat6 ep[Ti''! <br /> Describe Mater€ia1- and Procedure •^. <br /> I hereby agree to comply with all laws and regulations of the, Sari�Joaquin Local Health District <br /> and the..Staterof California-pertaining to-.or-regulating�well'`,construc <br /> - 'tion. Within FIFTEEN DAYS <br /> after completion of my :%rock on,a,news,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 o£ my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTZNG AND NAL INSP TION. ! <br /> SIGNED TITLE , <br /> + (DRAW.P OT PLAN ON REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED BY !� DATE ? <br /> �`7 <br /> ADDITIONAL COMMENTS: j <br /> PHASE <br /> .II GROUT INSPECTION PHASE IIJ/FINAL II/FINALINSPECTION <br /> INSPECTION BY DATE 5 -- --77 INSPECTION BY DATE 3 <br /> F. 3/121 1D-- ' 1_7i ry � 1/77 ?M <br />