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SAN JOAQUIN LOCALTH DISTRICT- <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> : :3 6 Telephone: (209) 1466,-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP''PERMIT Permit No. ]6-�7 Id <br /> 76 —s'-7y/0 <br /> THIS PERMIT EXPIRES 1 YEA FROM DATE ISSUED Date Issued ?� <br /> (Complete In Tilplicate) <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. 1862 and- the Rules and Regulatilons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 74?,5�i 9 11I. �,p �L✓ J CENSUS TRACT <br /> Owner's Name Mies Phone <br /> h Address opu_Q Al 'A/,.1",4�eAz z&jLg j City ,.sAxk4 K/ <br /> CS-7 <br /> Contractor's Name /� License hone 1166. 4444 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR f PUMP REPLACEMENT /-7 <br /> Other /_7 <br /> j. <br /> DISTANCE TO NEAREST: SEPTIC TANK 76 _j- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 'FIELD Q-'¢- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE/ASPRIVATE DOMESTIC WELL A PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / a ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven - Gauge of Casing ► Q i <br /> Irrigation 1( Gravel Pack Depth of Grout Seal ' <br /> Cathodic Protection = Rotary Type of Grout _ A • _ + <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:a Contractor oizowa, <br /> Type of Pump Allt a H.P. <br /> PUMP REPLACEMENT: . <br /> `. / / State Work Done I� � <br />.i-,PUMP_.REP.AIR-: _--_ ,--j..States Work Doner <br /> 3 Y I <br /> f 7 <br /> S-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> _— Dylll:�1 <br /> ribe Material 7 <br /> and Procedure 5 ter, <br /> I hereby agree to {comply with all laws and regulations of the San Joaquin Local Health District <br /> and the St o ifornia pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> after co letion of work on a new well, will furnish the San Joaquin Local Health District A <br /> WELL DR LERS REPORT of the wel a of y hem before putting the .we.11 in use. The above <br /> inform tion is true t the,lb s ow dge and belief. I WILL CALL FOR ROUT INSPECTION. <br /> PRIOR G UT N A FI <br /> SIGNED TITLE4 <br /> i D W PLAN:JON REURSE SIDE)- <br /> FOR <br /> IDE FOR DEPARTMENT USE ONLY <br /> PHASE' I <br /> APPLICATION ACCEPTED BYY DATE 2 7 <br /> ADDITIONAL GOMMUTS: <br /> PHASE II GROUT INSPECTION, zPHASE III FINAL INSPECTION . <br /> INSPECTION BY DATE 6 INSPECTION BY DATE 4-w <br /> E H 1426 Rev. 1�74 ... <br /> 3/76 2K .. <br />