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r SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FDE4OFFICE USE: 1601 E. Hazelton Ave, Stockton, Calif. <br /> Telephone:r­4(209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 'UMP PERMIT Permit No. Tilj.3/, ,� <br /> THIS. PERMIT, EXPIRES 1: YEAR;FROM.,,,PA E tiSSUED Date Issued -��7� I <br /> (Complete- in Triplicate) <br /> Applics,tion is hereby made to the San Joaqut-p, Local Realpthh.DiStrict',for;.a,permit to construct <br /> and/or install the work herein described. ,This applicat .at� is.made in.,,compliance with San Joaquin <br /> :County Ordinance No. 1862 and ,the: Rules-and_ Regulations of,°the,,San ,JQaquin Local 1lealth-Metrice. <br /> JCB-ADDRESS/LOCATION y . . u.CENSUSTRACT a'fS-fsb-iE. <br /> g. <br /> Owner's Name = -- laJrJ'u�o _ Phone ` <br /> Address _. _ Ifz / .Cit .. <br /> Contractor's Name License .# 7 Prone gfe j <br /> 4d <br /> ' J 7� <br /> k7 - <br /> TYPE OF WORT{ (Check) : NEW WELL / DEEPEN ? RECONDITION /_ DESTRUCTION /_7 } <br /> PUMP INSTLATION / / , PUMP REPAIR /7 PUMP REPLACEMENT /7 i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .&SZ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE--DOMESTIC' WELL-AQ: PUBLIC DOMESTIC WELL (� <br /> INTENDED USE T'Y'PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _e' Cable Tool __ :A.Dia. of Well Excavation (� <br /> _2�� Domestic/private Drilled --Dia. of-Well Casing / <br /> Domestic/public Driven Gauge of Casing, qLAW <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary- Type of Grout ,,;;; ? <br /> Disposal Other Othe.r .Information <br /> Geophysics] Surface Seal. Installed By: <br /> �rfl./Yf - -- <br /> PUMP INSTALLATION: Contractor _ _ el1 .0eYrcraza, °�X. - �yst�' rlYkl. � <br /> Type of Pump _ . ... . H.P.__::....,.:,..:......,,_.,eer <br /> PUMP REPLACEMENT: / / S tate' Work Done <br /> .. <br /> r -PUMP `.REPAIR; State work-Done - -- -r----- -- <br /> ESTRUCTION OF WELL: Well Diameter L Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations- of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. -Within FIFTEEN DAYS <br /> after completion of my work on 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 GROUTINSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION_. , <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY . <br /> - <br /> PHASE I <br /> APPLICATION ACCEPTED BY� DATE s . <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION P I.FINAL INSPECTION <br /> INSPECTION BY DATE -' INSPECTION BY� r DATE -/ <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />