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JOA <br /> ISAN UIN LOCAL HEALTH DISTRICT <br /> F� Q <br /> ?OR OFFICE USE : 1601 E . Hazelton Ave . , Stockton , Calif . a <br /> Telephone : (209 ) 4664781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No . 7� y78 <br /> 77,) .7 :5 p <br /> THIS ; PERMIT EXPIRES 1 YEAR FROM DATE. ISSUFD Date " Issued 3 -.3-woo7 <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 Joaquir <br /> aunty Ordinance No . 1862 and the- Rules and Regulations of the San Joaquin Local Health District , <br /> iI <br /> )B ADDRESS /LOCATION (�p eAce } CENSUS TRACT <br /> woo <br /> Mar s Name k f� n n . �I Phone) y" Z Z� <br /> �l,£ 3 x� <br /> ]dress n x��/ � e n a�ulA R hc� I ! City ' S &C10y o f <br /> mtxaCtor ' s Name. - ` #%R l� woo <br /> �Nc ` J.icense 1l,7d��d Phone,�dfGG� 39y <br /> fPE OF WORK (Check) : NEW WELL ' /o� DEEPEN ' / / RECONDITION / / DESTRUCTION /`j <br /> PUMP INSTALLATION � PUMP REPAIR • / / PUMP REPLACEMENT <br /> wooloo <br /> Other /! / <br /> loowl <br /> ISTANCE TO NEAREST : SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE D'ISPOSAL���� 5 ftELD ? 7CESSPOOL/SEEPAGE PIT OTHER 4 <br /> lowPROPERTY1LINE /24RIVATE DOMESTIC WELL '— PUBLIC DOMESTIC WELL --- 4 <br /> INTENDED USE TYKE OF WELL ` CONSTRUCTION SPECIFICATIONS <br /> if ololl-olow <br /> Industrial + Cable Tool Dia , of Well Excavation m;L <br /> Je Domestic /private — Drilled Dia . of Well Casting 3/c�N <br /> Domestic /public T Driven Gauge of Casing ! Z ;- <br /> Irrigation Gravel Pack Depth of Giout Of 5 V To P e <br /> _ Cathodic Protection Rotary Type of Grout _ gmM <br /> _Disposal + Other Other Information <br /> Geophysical y _ Surface Seal Installed By : r// ✓+PT' Ss <br /> UMP INSTALLATION : , Contractor OsutOe 11 :jAA Rveig � <br /> 411 Type of Pump H P 3 <br /> + <br /> RT REPLACEMENT : - / / State Work Done <br /> UMP REPAIR : / / State Work Done <br /> ;S•TRUCTION' OF WELL : Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i v <br /> i <br /> 'hereby agree to comply with ;all laws and regulations of the .San Joaquin Local Health District <br /> nd the. State of California pertaining to or regulating we11 ''construction , :. Within FIFTEEN DAYS <br /> fter completion of. my work ori a new well , I will furnish the San Joaquin Local .Health District a <br /> ELL DRILLERSXREPORT of the well and notify them before putting the'Well•^ Yn:use . Tae above <br /> nformation is true to the best of my knowledge and belief , I/ WILL ICALL. "FOR A_; GROIIT IN M% T,ON <br /> 3IOR TO GROUTING AND A FINAL INSPECTION: ' = c ' ` 1 <br /> IGNED TITLE , . , <br /> (DRAW PLOT PLAN ON- REVERSE SIDE• '- ,. 1. <br /> FOR DEPARTMENT USE ONLY , JL[ <br /> RASE I V / �y t o A ��, . 7 7 <br /> PPLICATION ACCEPTED BY c' ��!`�� �i� �"J � DA E J ` , <br /> DDITIONAL COMMENTS : e f 5 �� A <br /> PIAS `' 'I -' ROU ' AS ECTION' PHASF• INAI: iINSPECTr N\ <br /> NSPTC'TION 3Y DATE " G N�]'"f7GTION .B� - '" " DATE III F <br /> '� LdP. .: s�� � 1 / Z7 . _. + 2M' <br />