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_�^,!i I &'N JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOS. OFFICE L:T: ! . 1.601 E. H„zelton Ave. , Stockton, Calif. <br /> - - )RIV one: (STRU 460-6781 <br /> APPLICATION P)S 'ri El.l. CO6STFU!;PION OR PUMP PERMIT Permit No. ;7/_�?? /0 <br /> THIS 1YRMIT EXPIRES l YEAR FROM DATE ISSUED_ Date Issued i! <br /> (C,,.nplete In Triplicate) <br /> Application is hereby made to the Sin Joaquin Loce! Health D_strict for a permit to construct <br /> and/or install the work herein described. This ::oplication is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules ai.d Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION // G> �' S �`-�. •,' . -> > _ CENSUS TRACT <br /> n <br /> Owner, _ Name /�/.J� p — <br /> :J /� !.. / —_.—._— Phone <br /> Address i= -City ' S ' <br /> Contractor's Name '�,�r�✓.�.�% �._+i� _ License Il ��'!,��Phone <br /> TYPE OF WORK (Check): GEW WELL / / DEEPEN /_j RLC-tTDITION !_% DESTRUCTION /—j <br /> P.L <br /> PUMP !NSTLATION /z•/ PUMP REPAIR _/_% PUMP REPLACEMENT <br /> Uther f / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SFWAGr, DISPOSAL. FIELD _ CESSPOOL/SEEPAGE PIT _ OTHER _ ,A <br /> PROPERTY LINE - PRIVATE IXTMESTIC WELL PUBLIC DOMESTTC WELL X <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1^. <br /> _ Industrial Cable Tool Lia. of Well Excavation �\ <br /> X Domestic/private Drilled Jia. of Well Casing q <br /> — Domestic;)ublic Driven Gauge of Casing <br /> Trri.gat.on Gravel Pack Depth of. Grout Seal <br /> CathoJic Protection Rotary ,ype of Grout <br /> Disposal Ot:)er Other Inforsation A <br /> Geophysical ^� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pus:p H.P. 22 7 T <br /> �- <br /> PUMP State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 District a <br /> WELL 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 /> PRIOR TO GROUTING AND A FINAL LNSPECTrC:J./% % <br /> SIGNED�r_7 �.�ll r'.'. i TITLE <br /> (DRAW PLOT PLAT! ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I —_— <br /> APPLICATION ACCEPTED BY ^✓✓;- -_ - DATE <br /> ;J)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION_ F_H_SI': III/FINAL INSPECTION <br /> BY DATE tSSPI:c:Tlu:, !sY _ DATE <br /> E G 1426 Rev. 1-74 3/76 214 <br />