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_ SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> Fb6`OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> , Telephoner x(209) 466-6781 <br /> APPLICATION FOR-WELL CONST4UCT_ION OR PUMP PERMIT Permit No. -� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued d� // 'J/ <br /> (Complete In Triplicate) - <br /> Application 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 Joaquin . <br /> County Ordinance No. 18 d,.the Rules and Regulations of the San Joaquin Local Health District. <br /> zG - Sorvai/ ,, /1/ <br /> JOB ADDRESS/LOCATION E .Si�//jQe� �/�(��Q jj �Jdf 2G CENSUS TRACT 041 <br /> (-3ee-3y <br /> Owner's Name E E C/-an oa Phone <br /> Address City /hOCeN <br /> Contractor's Na v4���.�/. l�� /� ,E� ( cense # /9/hone AL_51_*24 <br /> TYPE OF WORK (Check): NEW WELL f/ DEEPEN/ / RECONDITION /77? DESTRUCTION 17 v <br /> PUMP INSTALLATION / / PUMP REPAIR /% rPUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 2 a + SEWERLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /_ 0+ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE3DrPRI•VATE •DOMESTI'C'WELL'L-c -' PUBLIC DOMESTIC WELL I ,_ G . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' r <br /> .,,r;o <br /> Industrial Cable Tool .—Daia._ of 'Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven -Gauge of,Cading /Qr;� , ��✓ <br /> J/Irrigation Gravel Pack Depth of Grout, Seal —� A(6 r <br /> Cathodic Protection Rotary Type of Grout — <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By: <br /> a r. <br /> PUMP INSTALLATION: Contractor q <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State,Work Done\ f- _ -> <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 comple n my work on. a new well, I, will furnish the San Joaquin Local Health District a <br /> WELf`DRILL S'1100R o_f,ithetwel 'and 'otify'them before',puttfng the_+well' in IB 'The, <br /> above <br /> informati is ru the be knowledge and belie 'I`WILL 'CALL FO {A� GROUT INSPECTION <br /> PRIOR TO OUT A F �^ : <br /> SIGNED -- - - .. _._^ --- -.TITLE. <br /> (DRAW,PLOT. PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT US ONL <br /> PHASE I <br /> APPLICATIONACCEPTED BY 0 J DATEAF <br /> - <br /> ADDITIONAL COMMENTS: ISZZ�7 IL <br /> PHASE II GROUT INSPECTION P10,V_j"I/F1NAL INSPECTION, . <br /> INSPECTION BY DATE INSPECTION BY —DATE 6 <br /> IIN " " 2M <br />