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FOLD OFFICE USE: L�f SAN JOAQUIN LOCAL HEALTH. y, - <br /> �/ 1601S E DISTRICT <br /> • Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> CONSTRUCTION OR p <br /> APPLICATION FOR WELL CONS <br /> UMP PERMIT <br /> • THIS PERMIT EXPIRE$ 1 YEAR FROM DATE ISSUED Permit No. <br /> Ar (Complete In Triplicate) <br /> Application is herebyDate Issued <br /> made to the San Joaquin Local Health Distract for a <br /> permit <br /> and/or install the work herein described. <br /> County :Ordinance No. 1862 and the Rules andThis Regulationstafn is made in compliancetwithnSan Joa u <br /> JOB ADD KESSlolthe San Joaquin Local Health Districtir <br /> /LOCATION Q � <br /> 'j Owner's Name <br /> ' CENSUS TRACT <br /> r <br /> k Address �Q'� Phone O� <br /> 4 Contractor's Nacre City <br /> License # 237 Phone <br /> .3 <br /> TYPE OF WORK -- + <br /> (heck <br /> : NEW WELL / / DEEPEN <br /> / I RECONDITION - <br /> PUMP INSTALLATION / / DESTRUCTION /7 <br /> Other / / / PUMP REPAIR /�/ PUMp REPLACEMENT <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FFIELD <br /> PROPERTY LINE - PRIVATE MESTIC CESSPOOL/SEEPAGE <br /> L SEEPAGE PIT <br /> — <br /> TYPE USE OTHER ) <br /> Industrial TYPE OF WELL PUBLIC DOMETS IC WELL' <br /> Domestic —�— Cable Tool Dia. CONSTRUCTION SPECIFICATIONS <br /> /private. ; Drilled of Well Excavation <br /> Domestic/public "-- Dia. of Well .Casing <br /> Irrigation --,� Driven Gauge of Casing <br /> Cathodic Protection' Grout <br /> P Gravel Pack Depth of � <br /> �� Rotary Seal_ CS ' <br />----,,,—Disposal Type of Grout <br /> Geophysical Other Other Information <br /> -----� <br /> Ak\ <br /> Surface Seal Installed $ 1. <br /> PUMP INSTAL / T <br /> CATION; Contractor ` r!J <br /> Type of Pump k `I <br /> PUMP REPLACEMENT: / / H.P.State Work Doneell / <br /> PtJMp`' AIR: <br /> REp <br /> Work Done �•.� -a� <br />)ES•TRUCTION OF WELL: Well Diameter �. <br /> Describe Material and Procedure Approximate Depth <br /> CLnd hereby agree to comply with all laws and regulations of the San Joaquin Local Heal <br /> if ter <br /> the St of Zifornia pertaining to or regulating well "construction. Within after co 1- -f o th District <br /> FELL D my work on a new well, I will furnish the San Joaquin LocalhHealth Distr a <br /> L S REPO T of the wet an ify them before <br /> nfor atian is t e o t be Putting the .well in use. The above <br /> RI0 TO G G D A n e ge an lief. I WILL CALL 0 <br /> IGN IO GROUT INSPECTION <br /> TITLE <br /> D' W PL T PLAN 'ON REVERSE S ID � <br />_ FOR DEPARTMENT USE ONLY ;:' <br /> SASE I <br />?P ICL ATION ACCEPTED By <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> fSPECTIE}N BY DATE PHASE III/FINAL INSPECTTON <br /> INSPECTION BY DATE — <br /> E H 1426 Rev. 1-74 <br /> 1/74 .�� <br />