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+ f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSIOFFICE USE: � 1601. E. Hazelton Ave..-, Stockton, Calif. <br /> Tele hone: <br /> p (203) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 749-/01 710 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Z2_2.-2,g <br /> r (Complete In Triplicate) <br /> .Application is hereby mads 'to the San Joaquin Local Health District for a permit to construct <br /> and/or install the Mork herein described. This application is made in with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONCJCW 1Y <br /> ENSUS TRACT <br /> Owne '® Namezllel " <br /> Phone ' oy <br /> Address. <br /> City <br /> Contractors Name License # r one, -19/ , ! <br /> TYPE OF WORK (Check): NEW WELL /77 " bEEPEN '/7 RECONDITION /-7 DESTRUCTION /-7 <br /> E PUMP INSTALLATION "/ / PUMP REPAIR / / PUMP REPLACEMENT f-7 <br /> Other <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 /> 1' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I Industrial —tCable Tool Dia. of Well Excavation 207 <br /> �0Domestic/private Drilled Dia. of Well Casing v <br /> I Domestic/public Driven Gauge of Casing <br /> f - it Irrigation Gravel Pack Depth of Grout Seal <br /> I Cathodic Protection Rotary Type of Grout <br /> 4 Disposal Other Other Information <br /> 5. <br /> 7/ . . <br /> #.Geophysical Surface 5ea1 Installed 'B `* ��'..•� :,�' <br /> PUMP 1INSTALLATION: Contr�acto��V,;_,;��' <br /> Type e�f Pump : r _ ' f'— <br /> U ,.. H.P. , <br /> PUMP REPLACEMENT: ' <br /> 4 / / Statei.Work Done <br /> PUMP ,REPAIR:; IState',Wvfk Done <br /> DESTRUCTION OF WELL: Well Diameter 4ApgroximaCe%Depth ` <br /> . � <br />{ Describe Material .and Procedure i <br /> I hereby agree to comply with all laws and xegulitions~of�`the San Joaquin Local, Health District <br /> and the State of California pertaining to or,.reguJldting,well `'construction. Within FIFTEEN DAYS <br /> afterkompletion of my work .on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL ,'DRILLERS REPORT of the well an;d notify ahem before putting..the. tWel1'. in.use.... The above <br /> information is' true to the•best-of my knowledge and belief. I WILL GALLFOR A GROUT INSPECTION <br />' PRIOR)TO GROU.TNG=AND A FINAL INSPECTION. <br /> SIGNED ;« -� ±�" ro ,' 61-- .. :-, ", .wr <br /> it TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> -- - FOR DEPARTMENTUSE ,ONLY <br /> ...---- <br />} PHASE' I <br /> APPLICATION ACCEPTED BY �� DATE o <br /> ADDITIONAL <br /> COMMENTS: -- . . - <br /> --`PHASE IT GROUTINSPECTION PHASE III FINAL INSPECTION <br /> E INSPECTION BY DATE INSPECTION B DAT <br /> F H_,142 Revs° 1-74 !t 75 _ 2M- <br />