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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />.OE 09FICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />,T APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3/!J <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,/�-�0-7(, <br />(Complete In Triplicate) <br />plication 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 />('aunty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JCB ADDRESS/LOCATION �,3jLU �� IQf��iLatf /UI /7CL � I� l�/t a w' kADA CENSUS TRACT <br />O 'per's Name <br />Phone <br />Address ad �cu.�/ � City _ <br />`,ntractor's Name <br />SPE OF WORK (Check): <br />NEW WELL / b/ DEEPEN /_/ R <br />PUMP INSTALLATION / / PUMP <br />Other /_7 <br />License if aZV4 Phone _522-1413 <br />CONDITION /_/ DESTRUCTION /-7 <br />REPAIR / / PUMP REPLACEMENT /% <br />:STANCE TO NEAREST: SEPTIC TANK 206' SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD 260 CESSPOOL/ SEEPAGE PIT OTHER <br />P'PnPRPTV T TMF - PRTUATR TH)MF.STTC WRT.T. PTTRT.TC DOMESTIC WELL - <br />11 <br />Domestic/private Drilled <br />Irmestic/public Driven <br />rigation Gravel Pack <br />_ Cathodic Protection �� Rotary <br />Disposal Other <br />Geophysical <br />JMP INSTALLATION: <br />JMP REPLACEMENT: <br />r <br />PUMP.REPAIR: <br />Contractor <br />Type of Pump <br />j_/ State Work Done' <br />State Work Done <br />CONSTRUCTION SPECIFICATIONS' <br />Dia. of Well Excavation / �' <br />Dia. of. Well Casing �p �y�- *, <br />Gauge of Casing <br />Dep LIL cf Grout Seal <br />Type of Grout <br />Other Information C/sE, <br />Surface Seal Installed By <br />C, <br />L <br />e <br />3STRUCTION OF WELL: Well Diameter Approximate Depth <br />Describe Material and Procedure <br />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 construction. Within FIFTEEN DAYS <br />after completion of my work on a new well, I will furnish the San Joaquin Local Health Distxict.-a <br />ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />PRIOR TOG UTING AND A NAL IN PECTION. <br />IGNED _;j XX�Ta (d-+,rj <br />TITLE X1 <br />� <br />' [DRAW PLOT ELAN ON REVERSE SIDE) , u <br />"RASE I / v <br />PPLICATION ACCEPTED BY (. DATE <br />7DDITIONAL COMMENTS: <br />PH� .II,GROyT INSPECTION PHASE III FIN INSPECTION <br />NSP�TION BY ,�. DATE INSPECTION BY %-2-c. DATE <br />T <br />3/76 2M <br />