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-rw <br /> n <br /> c6meA SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE VSZ 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ` APPLICATION FOR WFLL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4 TRIS PE`MIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> "F (Complete In Triplicate) _ <br /> is ,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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> x ,,JOB ADDRESS/LOCATION ��S � i►���, I,ft ��ly�j CENSUS TRncr <br /> _ <br /> �M �Owner's Name o? c --r e�� _ Phone <br /> Address i� f2 e City <br /> 1w� <br /> ,Coatraictor l s Nam< License # lt4 73.4 Phone -.-76 7Z <br /> �M:7PE OF WORK (Check): NEW WELL /_7 DEEPEN /-T RECONDITION /_7 DESTRUCTION /? <br /> �4;,r ;" ;in 4 AL <br /> - PUMP INSTLATION / / PUMP REPAIR /� PUMP REPLACEI�IT 1-T r <br /> Other /% .. <br /> n +° <br /> r i <br /> L3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> $ � � � - SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT { <br /> � OTHER t a � <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL ` ',;�4 <br /> INTENDED USE TYPE OF WELL CONSTRiJCSION SPECIFICATIONS `N <br /> � '~ Industrial _ Cable Tool Dia. of Well Excavat:on ��' <br /> a�r .Domestic/private Drilled Dia, of ;Nell Crying <br /> Doroestie%public r Driven Gauge of Casing <br /> �E�e ftriigation Gravel Pack Depth of Grout Seal <br /> 417 'y ,Cathodic Protection Rotary Type of Grout `b ��' \�►tYJ <br /> " `°Disposal Other Other Information <br /> fr9py+rr Geophysical <br /> Surface Sea: Installed By: <br /> PUMP }INSTALLATION: L Contractor -A:::;' <br /> ;.rr. .. -1- , j'.TYPe of Pump . Tu ✓ rs - --"' H.P. <br /> F{PUMP <br /> REPLACEMENT* / / State Work Done <br /> . aPUMP`REPAIR: State Work Done <br /> (DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> Describe Material and Procedure +f r <br /> V!'Thereby agree to comply with all. laws and regulations of the San Joaquin Local Health District.. <br /> J1 � <br /> and-the State of California pertaining to or regulating well construction. Within FIFTEENNDAYS1 , <br /> 4' fter, completion of my work on a new well, I will furnish the San Joaquin Local Health Dietrict,a <br /> }WELL`,DRILLERSREPORTof the well and notify them before putting the well a.n use. The above;. <br /> .7information,is true to the best of my ledge and-,,belief- I WILL CALL FORA GROUT INSPECTION-,' <br /> �. PRIOR TO,'GROUT( AND A FINAL I a I s �7 'S 1-0- <br /> 'RSIGNED �� a r< TLE -. J <br /> PLOT PLAN ON E SIDES <br /> ' r ti ,,, _• FOR DEPARTMENT USE ONLY <br /> i PHASE Ixl <br /> 'A APPLICATION,ACCEPTED-BY DATE <br /> "W)DITIONAL COMMENTS, e"'' <br /> %�f^�;' " PHASE II GROUT INSP ION PHAS ,XI/FNAL INSPECTIO I , ` fie <br /> ';INSPECTION BY Yw - DATE INSPECTION BY DATE43/ <br /> a G'F <br /> {r a ti <br /> � v'•1 r.i wa.1i 'r] 4 <br /> E H,1426- Rev. '1-74 _ I <br /> e r a {�-a• '�f �r a �,'; ��i t. ,. ,{ J�t"41y `�q,'y- y.k - r r ��ti�}'�.-e� ` 8 ir: <br /> T ,�.�w.'� .ra L a.�s,�. ; � ��'.t l+�A'���`=ar'i+�'��`�,��'(nhc>'i���`is�y��F�i ..».�t,.�'TL'i�17 t,`T�fi�ak�s'�a;,N��, .a ��'r(:�u� i 1� • <br /> r <br />