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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70Fs*OFFICE USE: 160 . Hazelton Ave. , Stockton, Cal,, <br /> Telephone: (209) 466-6781 -/ 2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7, <br /> (Complete In Triplicate) <br /> )plication is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> id/or install the work herein described. This application is made in compliance with San Joaquin <br /> )unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> )B ADDRESS/LOCATION /292,9'7 -5'M.44,4- QA. M.4A/2nEG14 CENSUS TRACT <br /> mer's Name /0AR2A7LL PORTOiV Phone 9. 2 <br /> 1dress rc}m'�F_ City 11,24WTEcfI <br /> )retractor's Name AlOAC/f AbIZVI-7 AV6 License #Zoo qPhone <f! - j7 <br /> tPE OF WORK (Check) : NEW WELL X DEEPEN /7 RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION jg/7 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> [STANCE TO NEAREST: SEPTIC TANK 2,yo, SEWER LINES �p'� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation /0// <br /> Domestic/private Drilled Dia. of Well Casing /, 1' <br /> _ Domestic/public Driven Gauge of Casing /2 614. v <br /> _ Irrigation Gravel Pack Depth of Grout Seal 5-p <br /> _ Cathodic Protection Rotary Type of Grout 6FAI7-0I//TE <br /> —Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: X10.4CK <br /> R4P INSTALLATION: Contractor C <br /> Type of Pump 4.,e - L E H.P. <br /> JMP REPLACEMENT: / / State Work Done <br /> JMP REPAIR: / / State Work Done <br /> iSTRUCTION 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 /> ad the State of California pertaining to or regulating well construction. Within FIFTEEN DAIS <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District 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 /> :IOR TO GROUNG AND A F AL INSP TION. <br /> IGNED TITLE <br /> /I (DRAW PLOT PLAN ON REVERSE SIDE) 001 <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY "41 4// i DATE t <br /> DDITIONAL COMMENTS : '91d S c 61 <br /> P II GP9UT INSPECTION PHASEIII/FINAL INSPECTION <br /> NSPECTION BY ✓j DATE /) ,l9_r/'� INSPECTION BY DATE <br /> A10 D 'U"'5 <br /> 1177 _ 2M <br /> E H 1426 Rev. 1-74 <br />