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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOP: OFFICE USE: ' GO 1601 E. Hazelton Ave. , •Stockton, Calif. <br /> t <br /> Telephone: (209) 4.66-67811-7-790 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V--3!ffp <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued5:-77 <br /> t ! (Complete In Triplicate) <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 Regulations of the San Joaquin Local Health District. <br /> lw2SS' w".'i- Q;' CENSUS TRACT 0 CS 0`447 —0.3 <br /> N <br /> JOB ADDRESS/LOCATIO , QP_1�i4 S S - <br /> Phone <br /> Owner's Name ' �/�YY1 C�-S <br /> ' Address City <br /> Contractor's Name / A.40 J ,�//Ll/�-� License 4� yS .Phone i rr- <br /> i - - <br /> TYPE OF WORK (Check) : NEW WELL-. -DEEPEN -/ RECONDITION-/_/_/ T:: _-DESTRUCTION /_7PUMP# INSTALLATION / PUMP- 'REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> :SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT = OTHER y <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION :SPECIFICATIONS <br /> s Industrial WCable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public; Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> i Cathodic Protection 1 Rotary ,-/ Type of Grout <br /> ` Disposal OtherOther Information <br /> Geophysical Surface'Seal Installed By: se/_tAjVZD <br /> FLSI/V <br /> PUMP INSTALLATION: Contractor b <br /> a Type :of Pump H.P. : <br /> PUMP REPLACEMENT:_ / / 'State Work Done <br /> PUMP -REPAIR: / / State Work.Done.. <br /> DESTRUCTION OF WELL: We11 '.Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ` I hereby agree to comply with all laws and regulations of the San Joaquin Local Health DistT:� <br /> and the State of Calffornia :pertaining to or regulating well ''construction. Within FIFTEEN DAA `. <br /> hafter completion of my work ,on a new well, I will furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of the twelland 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 TO GRORINf2 AND A FIN SPECTIO.N.. ' <br /> s SIGNED TITLE ' <br /> �_(DRAW_P_LOT PLAN_ON_,REVERSE SIDE) <br /> • FOR DEPARTMENT USE ONLY } <br /> PHASE I _2 �-�� <br /> APPLICATION ACCEPTED .-BY _ " DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONSE FIN INSPECTION <br /> INSPECTION BY DATE - =- INSPECTI'ON 'B ATE <br /> A N 11,9A Rov_ 7=74 <br />