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('6 o"+���" V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75�-336 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7/7- 7u <br /> (Complete In Triplicate) <br /> pplication is hereby 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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,.OB ADDRESS/LOCATION 7 K S LJ //r a r a e CENSUS TRACT <br /> wner's Name lri a-)t 6-:a c aya n Phone <br /> `Address 7 q- City n4d"I <br /> ' <br /> ontractors Name ,.� <br /> r, � �� rd �Fc7 License /) /f37s.fPhone Lt. 767G <br /> 4PE OF WORK (Check): NEW WELL /_ DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR Z� PUMP REPLACEMENT <br /> Other /% — <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ 7 Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> "UMP INSTALLATION: Contractor � > 7�--- 7�—C—� 4c2 <br /> Type of Pump � <br /> �;� r_dI/u H.P. 7 ✓ <br /> PUMP REPLACEMENT: / / State Work Done <br /> v- MW REPAIR: /% State Work Done <br /> :S•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> T 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 DAYS <br /> aTter 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 /> aformation is true to the best of my knowledg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ;..�;IOR TO GR TING AND A FINAL R I <br /> SIGNE u. - <br /> tc "TITLE �-a( <br /> RAW PLUT PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> .?PLICATION ACCEPTED BY DATE / <br /> `)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE cf <br /> E H 1426 Rev. 1-74 ,'`�,,.•,/ <br />