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Li a <br /> I <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR .OFFICE USE: ij 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 0 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued0�7i <br /> , . (Complete In Triplicate) <br /> Applica-tion is Nereby made to the San Joaquin Local Health District for a permit to construct <br /> and/8Y`J"install the work herein described. This application is made in compliance with San Joal <br /> County Ordinance No. 1862 and the Ru1j d egulati nof the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION �� CENSUS TRACT <br /> Owner's Name ii Phone 4 79 —4 -wg <br /> Address . _ a City R/ 011' <br /> Contractor's ',Name SA .� License # one <br /> q I _ <br /> TYPE OF WORKI!(Check) : NEW WELL '/ / DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION _/ PUMP REPAIR "/ / PUMP REPLACEMENT 1_7 <br /> Other! / / <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE`2IT OTHER <br /> I PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ti%ii CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool 4 y Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> i <br /> Domestc/public Driven Gauge of Casing <br /> f Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Type of Grout I <br /> Disposal Other Other Informationt <br /> Geophysical ! S dace SealjInstalled By: —� <br /> PUMP INSTALLATION: Contractor & <br /> T� Type of Pump H.P. <br /> E <br /> � PUMP REPLACEMENT: / / State Work Aone`�(3 <br /> . FI • 'tt - <br /> PUMP REPAIR: /7 . State Work Done <br /> DESTRUCTION OF WELL! ' Well Diameter 1 �.- <br /> Wvr� J <br /> I � � t`� Approximate Depth <br /> Describe Material and Procedure) I f i h i. <br /> I hereby agree to comply with.all laws and regulationsjof`the San Joaquin Local Health Distric <br /> A, / <br /> and the State of California pertaining to or regulating- well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish-the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of the well and notify them before pu:ttng the..well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI01 <br /> PRIOR TO GROUT G ANDA I13SPION. <br /> SIGNED d I � TITLE <br /> -.-(.DRAW_P,LOT_P.LAN-ON�-REVERS E SIDE) <br /> f Ali FOR DEPARTMENT USE ONLY <br /> PHASE I �� 3 0 J <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /�/ INSPECTION BY ATE 2_z- 7; <br /> 1( f � <br />