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SAN JOAQUIN LOCAL BEALTH DISTRICT <br /> OFFICE L 1'. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 'No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> A-��plfcation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> "or Insrali the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No, 1862 and the Rules aiid Regulations of the San Joaquin Local Health District. <br /> tZ2 <br /> JOB ADDRESSjLOCATIO?I A4 CENSUS TRACT Zq4 549'01 <br /> awner'sFNamc y All <br /> X?Cf Pt one .4a fZ- J, <br /> City <br /> ''ontractor's Name 4CII /, `.v4 License FZZ4L_q_ PhonePL,�- <br /> TYPE OF WORK (Check) : NEW WELLYT DEEPEN — RECONDITION /-7 DESTRUCTION /-7 <br /> FURP INSTMATION PUMP REPAIR /—/—PUMP REPLACEMEI�T-- /-7 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD --- CESSPOOL/SEEPAGE PfT OTHER <br /> PROPERTY LINi*P PRIVATE—D0-4ESTT C WELL'jQi2:4 PUBLIC <br /> INTENDED USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of ,Well Excavation <br /> Donyestic/private Drilled Dia. of Well Casing <br /> Dnmesric/pubiic. Driven Gauge of Casing <br /> Irrigatioa Gravel Pack. Depth of Grout Seal r <br /> CaRotary Type of Grout 4 1 <br /> dho,�:-iz Protection Other Other Informat ion j�+ 6 <br /> fl--)p bi y 8 i Cal Su-rface Seal Installed B <br /> PUYS, INSTALLATION: ContractoT <br /> Type Of <br /> jltM-1 REPLACEW�NT State tWork"Done <br /> �IUMP REPAIR, State Work Done <br /> i.ES OF WELL< well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1. hereby agree to comply With all. laws and regulations of the San Joaquin Local Health Bistrict <br /> arid t.17.e State of California pertaining to or regulating well `construction. Within FIFTEEN DAYS <br /> L Joaquin Local Health District 8 <br /> after comp-otion of my work an a new we] I will furnish the San <br /> 1— t fy them before putting the well in use. The Above <br /> .4-:T and n(,-.t i <br /> �,L DRILLERS REPORT of the well A, <br /> Is true th"e of nowledge and belief. I WILL GALT FOR A GROUT INSPECTION <br /> RIOR W�D A F0,AVNS' 1 <br /> TITLE <br /> S F,—Nh <br /> . ............... <br /> (D�RAW PLOT PLAN.,2N REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> p <br /> --'L.l CATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS® P S IN INSPEC <br /> PHASE 11 GROUT INSPECTION <br /> E <br /> ATE <br /> INSPECTION BY DATE INSPECTION BY <br /> /77 2M <br /> �7, <br /> fj :426 Rev. i-74 <br />