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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFs OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -77-as9aJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-11- <br /> (Complete <br /> 3-g_(Complete In Triplicate) <br /> Application is hereby made t6"the Sat: 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 <br /> 62 andiithe Rules and Regulations of the San 'Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> E F <br /> Owner's Name ' mac Phone , <br /> Address •�fCf ' ,(2 City <br /> r,Contractor's. Name' <br /> License # 90?1 Phone Z2/d / <br /> TYPE OF WORK (Check): NEW WELL " DEEPEN '/7 RECONDITION %-T DESTRUCTION f? <br /> PUMP INSTALLATION •/7 PUMP REPAIR/_7—PUMP REPLACEMENT f? <br /> - Other <br /> DISTANCE TO NEAREST: SEPTIC TANK7dj� ; SEWER LINES .> x. `,PIT-PRIVY *.M <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 6161-,,30" <br /> -a PROPERTYLLINE - PRIVATE DOMESTIC WELL'' PUBLIC DOMESTIC WELL <br />- INTENDED USE1 TYPE OF WELL1' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool :_Dia. �of Well Excavation " �- <br /> _ 1 Domestic/private Drilled Dia. hof Well Casing <br /> — om 'stic pu l'i'c ='- Dir3veti Gauge--of-Caning ,Y <br /> Irrigation ; Gravel-Pack ,Depth of Grout Seal <br /> Cathodic Protection / Rotary "3 FType of Grout 2 <br /> Disposal :: . _ Other '`�� , Other Information <br /> ;Geophysical ' u Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor -I <br /> Type .of Pump - f - g.P.3 c� <br /> PUMP REPLACEMENT: . j_/ State Work'Done <br /> - 1 <br /> PUMP '.REPAIR,: _ / / State Work Done T _ <br /> D ;TRUCTION,`OF WELL: 611, Diameter - �f 0�� - Approximate Depth <br /> Des be Material and Prdgedure <br /> Xz <br />' I hereby agrea, tb .comply with all 1 ws and reguiat a o the an Jin Local Health District <br /> and the State of'-California pe4taining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of y-wor-k�n 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 /> PRIOR TOG OUTING ANI) NAI! IIJ$PEcriox. <br /> SIGNED &jer TiTL3E <br /> (DW PLOT PLAN ON RE RSESIDE <br /> F DEP TMENT USE ONLY <br /> PHASE i � �� �•*� <br /> APPLICATION ACCEPTED. BY DATE �f -- <br /> ADDITIONAL COMMENTS: <br /> P E -1 G INSPECTI N PHAS I I N INSPECTION <br /> INSPECTION BY DATE -511d,177 INSPECTION BY 'Af4eLe. <br /> _ DATE <br /> E H 1626 Ren. 1-7G�%�l�l�0 f 2M <br />