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1 _ SAN JOAQUIN LOCAL. HEALTH DISTRICT <br />-:ICE USF: f 1601 E. Hazelton Aver, Stockton, Calif. <br />--. <br />Telephone: (209) 466-6781. 1111 / <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��� <br />TILLS PERMIT EXPIRES 1. YEAR FROM DATI.-. ISSUED Date issued '////�� <br />(Complete In Triplicate) �`]jjj <br />.pplication is hereby made to the San Joaquin Local Health District- for a permit to construct <br />nd/or install the work herein described. This application Is made in compliance with San Joaquin <br />ounty Ordinance No. 1862 and the Rules and Regulatl)ns of. the San Joaquin Local Health District. <br />welt- *,Z &ii677/61),Sr <br />011 ADDRESS/LOCATION/ ul,�'. CENSUS TRACT <br />wner's Name C- d L X11 ZC �1 �I�r .0p�phone _ 5_1! J, 7�J .. , <br />ddress Y" :/9. 4S7L' ���A —— - ---- City --- <br />ontractor's Name ` V} C ',)/[' ICS �_ � I.icvnsr. fl 1'hone <br />0E OF WORK (Check): <br />NEW 14ELL DEEPEN / <br />%' RECONDITION / / DESTRUCTION % J <br />PUMP INSTALLATION / / <br />PUMP REPAIR /-_/ PUMP REPLACEMENT /% <br />Other <br />SEPTIC 'TANK - <br />[STANCE .TO NEAREST: <br />SEWAGE DISPOSAL FIELD <br />_ CESSPOOL/SEEPAGE PIT -- <br />LINK -PRTVA'I'li <br />DOMIiS'I'IC_IJh:LL _-_ P1JI:IJC D(1M1'sSTIC hliLl. <br />INTENDED USE <br />TYPE OF WELL <br />COiJS'TRU(PI'ION SPECIPICA"!'IONS <br />Industria]. <br />Cable 'Tool <br />Dia. of Well Excavation s,—..------- <br />__ Domestic/private <br />Drilled <br />U(n, of Weli Casing •+ <br />Domestic/public <br />�/ /Public <br />Driven <br />---- ----- <br />Gauge: or Casing [ � <br />Irrigation <br />__,I/ Crave Pack <br />Depth of Grout Seal <br />Cathodic Protrctlon�/ <br />R.oLary <br />0LIle t <br />IPP'' of t:ronf- G i-' ' n <br />r.Z._.Lt_t � <br />Other ill " <br />_Disposal <br />GeophysicalSurface <br />------- <br />---lorwation <br />Seal Lnst,rl .led <br />JMP INSTALLATION: Contractor <br />Type of Pump ..--- ---- --- - H.P. --- ---� <br />JMP REPLACEMENT: / / State Work Done [} <br />JMP REPAIR: /7 State Work Done <br />:STRUCTION OF WELL: Well Diameter - Appru.;iniate Depth - \J <br />Describe Material and Procedure <br />hereby agree to comply with 11.7 laws and regulations Of the San .Ioaq,ri.n Loral Ilealth District <br />rel the State of California pertaining to of regulating woll construrt.iun. W10tin FIFTEV14 DAYS <br />i ter completion of my work on a new well., .I. 11111 I'urnicar the San Joaquin Lni.:rl Ileal0h Di s, t i.ct a <br />:LII. DRILLERS REPORT of the well and nntily 010111 hefo:o PuLting the wr!I in use. nic above <br />lformation is true to the best of illy knowledge and hel ief. f lJ[1•I. (::11.1. PUL• A GI<Ull't' INSPb;CTfON <br />_ . <br />;IUIt 'LU GRO TING AND , ANAL INSPECI'IUN.�/ I - - <br />(CNl•:D 1 l- <br />RAID PLOT PLAN 0 REVERSE SIDE) <br />FOR DEPARIMEN'r USE ONLY <br />IASL? I I l -- <br />'1'L1(:A'T1UN ACCEPTED BY -� - - DATt( /- l <br />1DiT1ONAL COMMENTS: _---�-�---t- -- - - _7 ..- <br />PHASE II GROUP INSPE 10N 1I14SE rII/-VINAI CNSPI?CTfON <br />I:IPEcTION Bir'. / ,�--- DALE �r INSI'I (' 1w) IiY -% - -- - - -- -r-- tl <br />