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c3 - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: If 1601 E. Hazelton Ave. ; Stockton, Calif. F / <br /> 1 - <br /> ji '• Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f--IYO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a Pit-Pit to construct <br /> and/or install the work lerein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862, and the Rules and Regulations of the San Joaquin Local Health Disttict. <br /> AMP rtl <br /> (JOB ADDRESS/LOCATION 7 a"iiLE � F�� 44 Ffe-rd .%r Rd CENSUS TRACT <br /> Owner's Name �o� �►„ ��e ase ?/-. Phone ���- ©8' g <br /> (Address I_�.0 / 41 <br /> n 'i.rat. City S'7acA7'nAY <br /> Contractor's Name VA ✓v a License IID Phone <br /> i! r <br /> (TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION/77/'7 —�"^"'•"�� <br /> PUMP INSTALLATION /% PUMP REPAIR/_�/• PUMP REPLACEMENT '" <br /> Other /% - r- <br /> DISTANCE TO NEAREST: SEPTIC TANK_ bpd SEWER LINES PIT PRIVY <br /> "" <br /> SE4AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER `11 <br /> " Y PROPERTY LINE - PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 1 Industrial Cable Tool Dia, of Well _.Excavation <br /> Domestic/private Drilled Dia; of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> (/'Irrigation I: Gravel Pack Depth .of Grout 'SealJ t <br /> F. Cathodic Protection Rotary Type of Grout <br /> Disposal I' Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> Ik ! . <br /> 1°UMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> I?UMP REPLACEMENT: State Work Done�oav[21' <br /> ?UMP :REPAIR: / ;{/ State Work Done '3 <br /> RE TTRUCTION OF WELL: Well Diameter <br /> 1 Approximate Depth <br /> Describe Material and Procedure <br /> " Y <br /> IC hereby agree to complyrywith all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS y <br /> :f ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before puttingthe. well in use... The above <br /> .nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROU. ING A FINAL INSPECTION. <br /> 1 IGNED 4 ,� TITLE <br /> u (DRAW .PLOT PLAN ONYREVERSE SIDE) <br /> j <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> IPPLICATION ACCEPTED BY DATE <br /> LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II/F NAL INSPECTION k <br /> NSPECTION BY .IlIfjf. DATE INSPECTION BY DATE $_� <br /> N ! <br /> E,1,1426 Rev. - I-74 11 6/77 2M <br />