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_� SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FCE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (Z09) 466-6781 <br /> APP ICATION FOR WELUiCONSTRUCTION OR PUMP PERMIT Permit No. 7 7-/j 7!J <br /> »—moiTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued d-;7y:-7) <br /> (Complete In Triplicate) <br /> Application is bereby 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 /> County Ordinance No. 1862 and the Rules and Regulations of the <br /> San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1 (09 !9,0 N �. OGuS� !✓�e_�. T ,a a CENSUS TRACT - .•, <br /> .Owner's Name r P rs cP.u� Phone 3b$.- 9'410 j <br /> TAddress (oQ SQ N L o c 1 �o City L o cl <br /> .Contractor's Name c�„ w.G� License 6 � .1� Phone �G-9G <br /> •:.ii <br /> _TYPE OF WORK (Check) :N6W WELL/�,.�DEEPEN./�-; RECONDIT-ION. /� DESTRUCTION Jill <br /> —PUMP-INSTALLATION X- -PUMP-REPAIR / J__ PUMP REPLACEMENT_ J_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 410# SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALFIELD +. CESSPOOL/SEEPAGE PIT OTERR <br /> PROPERTY LINE4B1RIVATE DOMESTIC WELL 30! -.PUBLIC DOMESTZC,NELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well •Excavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing " Q <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection )e Rotary Rotary Type of Grout n � • <br /> Disposal Other --•Other-Information <br /> Geophysical j Surface Seal Inat lied B -T' <br /> * rc Imo'. .. I <br /> PUMP INSTALLATION: Contractor 1 `�+ + 1�lww..��s - <br /> Type of Pump SC; B.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> PUMP REPAIR: - --L:7-- State Work Done i - <br /> V <br /> eDESTRUCTION OF WELL: Well Diameter Approximate Depte <br /> Describe Material and Procedure - <br /> I hereby agree to comply withk-all-lawh'add_ regulations of the San Joaquin Local Health-District <br /> and the State of California pertaining`,to of regulating well'cot(structioa. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish.',.the,.4an Joaquin Local Health District " <br /> "WELL DRILLERS REPORT of the well and notify them before puttl 6 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 /> 4ERIOR TO GROUTING AND A FINAL INSPECTION. - <br /> ''SIGNED <'� TITLE <br /> " DRAW PLAN ON E'S1:DE - <br /> :� OR DE ARTMENT USE ONLY <br /> PHASE I rU/) - DATE <br /> �aAPYLICATION ACCEP <br /> _`- ADDITIONAL COMMENTS, <br /> PHASE II GROUT INSPECTION SE I AL IIOBPI ON • ,.,.��* <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />