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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F0� OFFICE USE: <br /> Telephone: (209) 466-6781 Permit No. �W7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ?7 p <br /> Date Issued 8'r <br /> THIS PERMIT EXPIRE$ 1 YEAR FROM DATE ISSUED --?� <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local Health District for a p with <br /> and/or install the work herein described. This applicationthe is Sane.Ioaquin Localin eHealthSDistrict n ', <br /> County Ordinance No. 1862 and the Rules and Regulations <br /> �ENSUS TRACT <br /> JOB ADDRESS/LOCATION � B /4f� � • <br /> Ph one I �o2 <br /> Owner's Name t ,� <br /> City <br /> Address <br /> ` E (VIM, <br /> S Phone 1 <br /> License- <br /> Contractor's Name <br /> TYPE OF WORK- (Check} ; NEW WELL / -DEEPEN / / RECONDITION /7 DESTRUCT-ION <br /> mp RE ACEMENT�R <br /> T ., <br /> PUMP INSTALLATION I�-}�T�TMP REPAIR '/ <br /> , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -�� <br /> SEWER LINES IT PRIVY- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL. PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> Industrial V-Fable Tool Dia. of Well Excavation ` �` <br /> r Drilled Dia. of Well Casing ;' <br /> �T}ostic/private Driven Gauge of Casing 3 r" <br /> Domestic/public LF ` <br /> Irrigation Gravel Pack Depth of Grout Sealf <br /> Rotary Type of Grout q <br /> Cathodic Protection Other Information <br /> Disposal Other -- <br /> � Surface"Seal In <br /> -Geophysical <br /> stalled B <br /> t ! <br /> PUMP INSTALLATION: Contractor H.P,• <br /> Type of Pump <br /> PUMP. -REPLACEMENT:f �A / / State,-Work Done <br /> _ t <br /> PUMP .REPAIR• / State Work Done '---- <br /> y <br /> DESTRUCTION OF WELL: Well Diameter' <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulnliatin °well'construction.Local <br /> Within' FIFTEENDistrict DAYS <br /> and the State of California pertaining to or reg gcral <br /> after completion of my work on a new well, I wlbeforefurnish <br /> uttingathe�wellninouse.HeThehaboverict a <br /> WELL DRILLERS REPORT Of the <br /> well and notify themP <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAM IN I <br /> ON, TITLE <br /> �. SIGNED <br /> P 'T PLAN ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 7 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FI AL INSPECTION <br /> �.. PHASE IT GR T INSPECTION INSPECTION BY DATE <br /> DATE 5` <br /> INSPECTION BY ` <br /> . 3%76 <br /> E H 1426 Rev. 1-74 <br />