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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFOB OFFICE USE: <br /> ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9-37 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Local Health <br /> stct <br /> ,4pplication isAereby made to the San Joaquin lication tz <br /> is incompli nt <br /> cewithnSan Joaquin <br /> and/or install the work herein described. This app <br /> County Ordinance No. 1862 and the. Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> -JOB ADDRESS/LOCATION �� ROP N ,Qi:fes <br /> Phone 36�6�9z <br /> Owner's Name 'nar <br /> i �1< a a� <br /> city lies � <br /> Address <br /> 1Q y/ ((�� ��' License at 30903 Phone 7� -S 8 <br /> Contractor's Name Y ¢""'r � '- <br /> J � <br /> wTr r ` DESTRUCTION C7_ <br /> TYPE OF WORK (Check) : NEW WELL / (_ DEEPEN /Z:/ ' RECONDITION /=7 <br /> PUMP INSTALLATION L / PUMP REPAIR/ / PUMP REPLACEMENT �I , 1 <br /> Other r/% W <br /> I <br /> _ <br /> DISTANCE TO NEAREST: SEPTICrTANK SEWER LINES PIT PRIVY _ <br /> '- SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT` r. OTHER `Ci! <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPB OF.WELL CONSTRUCTION SPECIFICATIONS <br /> ation <br /> Industrial - Cable-Tool------- Dia—of Weli-Excav <br /> Domestic/private. , Drilled Dia. of Well Casing <br /> Domestic/public - Driven - Gauge of Casing <br /> Grave-l-Patk�^--rDep-th-of- Grout-Sea17—"''-'- <br /> Irrigation R;- '- yp <br /> Cathodic Protection, Rotaz .- .- �"'T e I Grout <br /> --`Other Other Information <br /> Disposal f. -� � Surface Seal Installed BY'. <br /> Geophysical . , _ t •, :. <br /> PUMP INSTALLATION- Conrr ctor <br /> Type iof PumpH. 10 <br /> r , <br /> PUMP REPLACEMENT: State Work Done <br /> State Work Done - - - Ate/ <br /> PUMP REPAIR: / / , -- �-- - -- J <br /> Q Approximate Depth <br /> f DESTRUCTION OF WELL: Well <br /> Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all' laws� and regulations of-the San Joaquin Local -Health EN DAYS <br /> and the State of California,pertaining to or;regulating well 'construction'. Within FIFTEEN DAYS <br /> 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. thebest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI <br /> OP <br /> PRIOR TO GRO�ITING AND A F NAL INSPECTION. TITLE Ow <br /> SIGNED -.n'1 .c-r�'..�"'`�(D W FLOT PLAN ON REVERSE SIDE) - <br /> PHASE I FO DEP MN' USE /OJNLY r7 <br /> � DATE (� <br /> APPLICATION ACCEPTED BY- II , �4"— <br /> �,l <br /> ADDITIONAL COMMENTS: .f. PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 7 <br /> INSPECTION BY DATE ______ —/ <br /> 1/77 2M <br /> �G oe.. 1-74 - < - <br />