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A . GA(jC LOCAL IiEALTH VISTRII'n <br /> FOfi3OFFICF USE: 1601 E. Iiazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 456-6781 <br /> APPLICATION FOP WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7y=-3-6Z4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Uealth District for a permit to construct <br /> d/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> LB ADDRESS/LOCATION36 Q0 C6LO Z� <br /> nnW ENSUS TRACT <br /> Y <br /> ^aner`s Name !•,',., 1� 7C))1 _Ol �L Phone Y555 - ," 797 <br /> �ddress d_3600 <br /> City <br /> 4 mtractor s Name Fj��s1/ (nT�L License # Phone <br /> ,_>>2� -//z�/ <br /> �tPE OF WORK (Check) : NEW WELLDEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/—PUMP REPLACEMENT /7 <br /> Other /_7 — <br /> `,_STANCE TO NEAREST: SEPTIC TA14K SEWER LINES PIT PRIVY V <br /> x SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL 6 <br /> INTENDED USE TYPE OF {JELL CONSTRUCTION SPECIFICATIONS <br /> L Industrial Cable Tool Dia. of Well Excavation �[ i <br /> _1,/ Domestic/private Drilled <br /> Dia. of Well Casing (2 S/x n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal� SO i <br /> Cathodic Protection Rotary Type of Grout /c_J/�0!y ?fMA_tji i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> r <br /> PUMP REPLACEMENT: / / State Work Done - 30 - 7 <br /> iMP {REPAIR: /% State Work Done <br /> )PSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r <br /> Describe Material and Procedure <br /> L hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I .d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 6oter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 4ELL DRILLERS REPORT of the well and notify them before putting the. well in use. The above <br /> ' .formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO C <br /> IROUTING AND INAL IN Cr <br /> iIGNED i, TITLE j <br /> DRAW LOT P ON REVERSE SIDE) <br /> OR DEP F4 T USE ONLY <br /> SE I � ATE _ 7_ <br /> L <br /> APPLICATION ACCEPTED 'BY J <br /> ILL��DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P Z / . NAL INSPECTION 7 <br /> INSPECTION BY DATE INSPECT DATE <br /> E H 1426 Rev. 1-74 <br />