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—t-'-� SAN JOAQUIN LOCAL HEALTH DISTRICT n <br /> FOE OFF'1ICE USE: tjAf 1601 E. Hazelton Ave. , Stockton, calif. ' <br /> I • Telephone : (209) 466-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k - 5s kl <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> .s-sf 77 <br />', Application is 'hereby made t o the San (Joaqui.neLo alriplica HealthtDistrict for a permit to construct <br /> In <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. r1862 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address d � I <br /> � city: <br /> Contractor's Name <br /> License #a9QRj9 Phone -53�, p <br /> Gc� � . <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN/7 RECONDITION /_/ DESTRUCTI _ a <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY. LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of-Well Excavation ' <br /> mestic/private Drilled Dia. of Well Casing <br /> Domestic/public = Driven " • Gauge'of Casingv f <br /> Irrigation _ 16-9 <br /> Gravel Pack _ ` Depth of Grout Seal <br /> �= Cathodic Protection c�Rotary °;, ;:Type of Grout <br /> Disposal Other Other Information e <br /> Geophysical f <br /> Surface. Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT <br /> S td-te Work Done j <br /> PUMP REPAIR; <br /> / / State W7)rkZ44DQne <br /> 1 STRUCTION OF WELL: <br /> Well <br /> Des "tame er _ Approximate Depth <br /> er be Material and Procedure <br /> hereby agree to comply with all laws And regulations of the San Joaquin Local He lth District <br /> tnd the. State of California pertaining to or regulating well "t'onstruction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of-the sell and,-notify them.before -putting- the wellin use. The above r <br /> nformation is true to the best: of `my:knowledge= and belief I WILL CAL•_L�FOR A GROUT INSPECTION <br /> RIOR TO ROUTING AND A FINAL INSPECTION. <br />'IGNED !nn TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDL.) <br /> FOR DEPARTMENT USE ONT�Y <br /> RASE i �1 f W /S S <br /> la �a �'�l <br /> PPLICATION ACCEPTED BY ��" ., ,�/D <br /> DDITIONAL COMMENTS: �E�_ <br /> PHASE II GROUT INSPECTION PHASE /FIN INSPECTION <br /> NS� ��Np�B,Yf� DATE' 3 -7 ISPECTTON BY DATE =� _ <br />. .E .H 1426 Sl <br /> . 7L .,1777 . oiu l <br />