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r <br /> I <br /> i r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 7, FO6 OFFICE U--SEe /1601 E. Hazelton Ave._ Stockton, Calif. <br /> _ Telephone: (209) 666-6Iyl <br /> < APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L7,1;7 4J <br /> 77,400 9P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . < <br /> 7 (Complete In Triplicate) <br /> Application is hereby Inde to the San Joaquin Local Health District for .t permit to construct <br /> `! and/or install the work herein described. This application is made in compliance with San Joaquin <br /> < Cmnty Ordinance N�. 1862 andC the Rules and Regulations of the <br /> eelSSaann Joaquin Local Health District. <br /> JOB ADDRESS/LWjA=0W (} �iYi'0'9S-;' 2&1 G A?117 CENSUS TRACT <br /> 0.nxor's Name f$�S.`DY) /`� Phone <br /> ' Aed 7s City ��w _s{ <br /> r :,..:actor's Name OY u . <br /> !� j License OV�Phoueg.3�=f�,.-- <br /> TYPE OF WO" (Check): NEW WELL _.Oa DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER.,LINES O PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD 1804-CESSPOOL/SEEPAGE PIT 3C .?"OTHP.R <br /> yZS ti <br /> PROP17RTY I.IN RIVATF. DOMESTIC WELL � PUBLIC DOMESTIC WF.LL7� r U <br /> INTENDED USE: TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� i <br /> _ Industrial Cable Tool Dia, of Well Excavation _ _14 <br /> Dosc,stic/private Drilled Dia. of Well Casing _ 4/ <br /> I Dome etic,,)ub lic Driven Gauge of Casing \ <br /> _ Irrigation Gravel Pack Depth of Grout Seal ' <br /> _ Carhodic Protection Rotary Type of Grout _�glyt <br /> � <br /> I � Disposal _ Other Orher Information <br /> Geoplkysical Surface Seal Installed By: <br /> 1 PUMP INSTAI.I,%TION: Contractor i air \, <br /> Type of Puml C H.P. <br /> lAa` <br /> PUMP REPLACEMENT: L/ State_ Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth — <br /> Describe Material and Procedure <br /> _ L <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well ^onstruction. Within FIFTEEN DAYS <br /> i after completion of my work on a new 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 of my knowledge and belief. I WILL CALL. FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL. INSPFCr I.I. <br /> SIGNED _ c—� ITLE <br /> REVERSE SIDE <br /> FOR DEP RTHENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �, DATE S/ /Szzz <br /> ADDITIONAL COUNTS: <br /> PHASE 11 GROUT I`:SPECT_ON PHASE III/FINAL INS11FCTION <br /> INSPECTION BY _ DATE 77� INSPECTION <br /> c n ILIA e.... /_7:. 1177 2m <br />