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SAN JOAQUIN LOCAL HF.ALTN DISTRICT <br /> POF. OFFICE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRICTION OR PUMP PERMIT Permit No. 7�-7 <br /> 1 <br /> THIS PERMIT EXPIRES 2 YEAR FROM DATE ISSUED Date Issued <br /> Application is hereby ride t (Complete In Triplicate) ( ?F— a� -7/ <br /> o the San Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application 16 made In compliance with San Joaquin <br /> County,Ordinance.No..1862.and-0e .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t 4 -4 - <br /> Afeaf � a�f. � `l /o,../ CENSUS TRACT <br /> Owner's Naw f <br /> 2.id.L.�'t:�i=►n«PY�e S'- <br /> Address a Phone_ <br /> -- /3°�_�/�Z City S'& C/1Aa A, <br /> Contractor's Nam¢ L41't 'if �,1Z4lwo Llcenae e3 ! r Phone ;7.2 -7 <br /> E <br /> TYPE OF WORK (Check) : �NFW WELL K DEEPEN /-7 RECONDITION Q DESTRUCTION /7 <br /> ^' tPUMP INSTALLATION / PUMP REPAIR /-7-PUMP REPLACEMENT /-7 <br /> w '' Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES 1 era PIT PRIVY <br /> SEWAGE DISPOSAL FIELD fOd/ CESSPOOL/SEEPAGE PIT' OTHER N <br /> PROPERTY AV—OF <br /> - PRIVATE. DOMF..STIC W LL _ PUB Ac DOMESTIC WELL. <br /> INTENDED USE TY['E OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria, t Cabl ooI Dia. f Well Excavation <br /> �- Domestic/private t Drs ed Dia. o We11/Caefi�g t <br /> Domestic/public E Or en Gauge of Casing <br /> Irrigation G Vol Pack DeOth of Cf®ut Seal i i <br /> Cat?iodic Protertion !'�_ R tary N, pe of Grout er - <br /> Disposal 0 her Other Inforretion t r Ea <br /> Geophysical Surface !Loa' Insrailed By: <br /> PUMP INSTALLATION: Contractor 'i a' <br /> /`>o r� r',a rte. -�-` i <br /> Type of Pump H.P. <br /> PUET REPL�ICL'!lLNiI: / I SLge` ric Dane <br /> PUMP. REPAIR:_ rFJ. jN- c Work'Done <br /> De5TRUCTIO_N OF WELL: 1 Diameter Approximate Depth E � <br /> ribe Material sad Procedure c <br /> [ hereby agree to comply w th a22 laws and regulations of the-San Joaquin Local Health District J7 <br /> and the State of Californi pertaining to or regulating well construction. 4fehia FIFTEEN DAYS ; <br /> after completion of my wor onla new well, I will furnish the San Joaquin Local Health District _ <br /> WELL DRILLERS REPORT of t e well and notify them before putting the well in use. The above <br /> infoitration is true co th best of my knowledge and belief. :I WILL CAL'- FOR A GROG? INSPECTION <br /> 'RIOR TO GROUTING AU1 I INSPECrifin. r <br /> SIGNED TITLE <br /> RAW PLOT PIAN 04 REVERSE SIDE <br /> USE ONLY r <br /> PHASE I <br /> CATION ACCEPTED BY DATE <br /> 'f'7C.a TONAL COMMENTS. T 17i <br /> _PHA_SEE �11 GROUT INSPECTION y v <br /> PHASE 2I FCNAL INSPECTION <br /> !NSPECTION gY --y DA E ' �' NS GNI N RY--� DATE 7y <br /> , fh <br /> F, H 1426 v. 1_74 "-' <br />