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r -T4 <br /> _ g <br /> _ - .—. _ _.._.,.- - _-�:-; ,,.__.'.._,"__.—•----- -,..._,. .,...,...� .. _. ..._..�-.-. .M. FFA 3 s.`'. __�..� .._.,__.,_ ' _ <br /> { SAN .JOAQUIN LOCAL HEALTH DISTRICT ,: �. 41 FIS <br /> FOh.OFFICE USE: 1601tiE. Hazelt6n Ave. , Stockton, Calif. . 02 <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 IssuedA_ <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 withi 'San Joaqu',n- <br /> County Ordinance No. 1862 and the Rules and Regula -19 of the San Joaquin Local Health Distract; • . <br /> JOB ADDRESS/LOCATION 11.4ZZ 6440,gJ ' �9 AMC&P_ Ul / 3$U$ TRACT.: <br /> Owner's Name qV ,p.;", U= Phone JO .or - <br /> Address r_ 664a AM. <br /> Cit -.,. <br /> y &rC44 Az <br /> Contractor's Name License #3_21232 Phone 6,Q-JZ;77 Y. <br /> TYPE.OF WORK (Check) : NEW WELL J` DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP. REPLACEMENT y-7 k <br /> Other / '/ I <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /,Od CESSPOOL./SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Sr{ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled. Dia.' of Well Casing. <br /> Domestic/public <br /> ; <br /> /p Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth �of Grout- Seal <br /> Cathodic Protection �_ Rotary Type`of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor x ,tr 7�a�✓ rC; <br /> Type of'-,Pump H.P. - <br /> PUMP REPLACEMENT: # - _ <br /> State Work Done <br /> PUMP :REPAIR: / / State Work Done 4 :s <br /> ,> . <br /> DESTRUCTION OF WELL: �� l1 Dier - <br /> We . . <br /> "Approximate Depth` <br /> Describe Material and Procedure <br /> . j <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 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 /> information is true to the best of my knowledge and belief. I WILL CALL_FOR A GROUT INSPECTION # <br />?RIOR TO GROUTI G AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT. PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: { <br /> PHASE II GROUT 'INSPECTIONPHAS II/FINAL INSPECTION <br /> INSPECTION BY DATE Z/ "7 8 INSPECTION BYk2jPjUAjjfw DATE Z L t <br /> E H`1426 Aev. 4_74 1177 /. 2M <br />