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V, <br /> - -- SAN JOAgUIN LOCAL ZEALTH DISTRICT <br /> F ]� ,OFFICE USE: 1601 E. Haxel'toxz -Ave':., �Stiiekton, Calif. <br /> A Telephone:y,.,.(209) 466'= 6:781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-37,PW <br /> e THIS P.ERMZT;EXP;IRES 1 ;YEAR`::FROM,DATE:r16S <br /> UEDA;.:4•!,rtz<IDate''Ts®ued <br /> �1m•,:Tr3 11cate): .,.. f' :� .: �3en .�� <br /> Application is hereby made to the San- Joaquin _Laca1,�Health- District for a.spermi.t°to 'coi:siruet <br /> and/oyr .ins Call ;the.,woack herein described .Thies ZOAF10 jCon Ana P incompliance with'SAistricuinCount 'Ordinance No 1862 -and the;Mules Sand,;Re fiJoaquin,Local'Health District. <br /> JOB ADDRESS/LOCATIONCENSUSriTRACT 053=102-0-,l7` <br /> '.�_' <br /> Owner°s Name Phone <br /> e- �_ �'.'.' h,«.;r �. -.t:'••1�x R>vM..,tX.a. iv,e..., er . f <br /> Addice'ss r . r.�. "City . <br /> c <br /> CoAtractor's:.Name,. _ ' Y,•Ucense i`-_cl q hove l 1 <br /> TYPE OF' WORK (Check) NSW WELL / . DEEPENRECONDITION /77 DESTRUCTION 4/7 <br /> a # PUMP INSTAILATTON, / PUMP REPAIR, /__/ ' 'UMP REPLACEMENT t p <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK :. SEWER-, LINES ' 1 PIT PRIVY <br /> : SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE'PIT: OTHER ,1 <br /> 4PROPERTY LINE. - PRIVATE DOMESTIC VtLL` P'iJBLIC DOMESTIC WELL { <br /> `.INTENDED FTSE, :TYPE. OF WELL a t CONSTRUCTION SPECIF.ICATTONS j <br /> :Industrial _ Cable Tool Dia. of Well Excavation .r <br /> z.;-, Domestic/private s Drilled Dia'. of Well Casing ' <br /> Dome ie 3#c./.public :�Dr ve t Gauge of�Casi / `� <br /> t '�,Irr:igation Gxavel:'Pacic Depth of Grout'. Seal <br /> f Cathodic Protection-._,.'" Rotary', L Type of Grout <br /> t DiaposAl Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: "i 3 Contractor <br /> t Type ',of Pump _ -- -- - - H'.P. <br /> r <br /> PUMP REPLACEMENT: L/ State Work Donex4i < <br /> PUMP '.REPAIR-:» ,�,��. ? /7--state -Work`Done:-- <br /> j3ESTRUCTION OF WELL: Weill Diameter Approximate Depth <br /> al;and Procedure <br /> ` <br /> dure <br /> I hereby agree to domp1Ywith all laws and reg ulations of the San .Joaquin Local Health District <br /> . <br /> and the State of .California pertaining, t 1 regulating well 'cons'ttddtion. " Within FIFTEEN DAYS <br /> after compleiion of my work. ;on ,'a, new T' I .will. furnish the .San ,Joaquin Local 'Health District a <br /> WEi�L DRILLERS REPORT of the well and notify them before putting.. tlie..well in.use.. . The above <br /> information is, true to the'bestl; of,l my-knowledge and' bell 6f.: I '.Wife' CALL FOR A`GROUT' INSf ECTION <br />' PRIOR TO GROU NG AND A FINAL INSPECTION. <br /> SIGNED TITLE + 'E <br /> (DRAW PLOT PLAN ON REVERSE.SID <br /> . A i .. i F• k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. E... <br /> APPLICATION 'ACCEPTED 'BY. ' ' s DATE a ' <br /> ADDITIONAL .COMMENTS <br /> =PHASE "SII GROUT INS CTION PHASE III FINAL INSPECTION . <br /> INSPECTYON BY (' DATE INSPECTION BY DATE /f / Z.t' <br /> t E H 1426 Rev. 1-74 1-74 2M <br />