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SAN, JOAQUIN LOCAL HEALTH-DISTRICT <br /> ,4 <br /> FO OFFICE USE: 1601 E. Aazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Permit No, 7 -3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ----- <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued: <br /> (Complete In Triplicate) <br /> Application is hereby made to the San JoaquiniLsocaall �gha�District <br /> de inrcomplia cetwithnSan Joaquin <br /> and/or install the work herein. described. Th PP ` <br /> County Ordinance No. 1$62 and the Rules, and Regulations of the San `Joaquin Local Health Distri`ct'. <br /> //" CENSUS TRACT <br /> JOB ADDRESS/LOC AT N O <br /> Phone <br /> Owner's Name . <br /> City : <br /> Address /Co <br /> LicensePhone <br /> Contractor' Name <br /> TYPE OF WORK (Check): NEW WE /�T DEEPEN // RECONDITION 17 DESTRUCTION ONLY <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / 1 <br /> DISTANC <br /> E TO NEAREST' SEPTIC TANK �__ SEWER LINES PIT PRIVY <br /> SBWAGE DISPOSAL FIELD, _ CESSPOOL/SEEPAGE PIT OTOS <br /> PROPERTY LINE - PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC L <br /> { INTENDED USE TYPE OF WELL - i CONSTRUCTION: SPECIFICATIONS , . <br /> industrial Cable Taol Dia. of Well- Excavation <br /> Domestic/private Drilled Dia. of Well Casiug <br /> Driven E Gauge of Casing <br /> ti Domestic/public Depth of Grout Seal <br /> Irrigation Gravel Pack -_ _P <br /> Cathodic Protection Rotary Type"of Grout <br /> Other Other.Information }Y h <br /> _Disposal ==" <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ;,PUW REPLACE: . / / State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br /> AES•TRUCTTON OF WELL: Well Diameter <br /> Approximate Depth <, <br /> Describe Material and" Procedure <br /> I ,'hereby_agreewto comply with all laws and _regulations of the San Joaquin Local Health Dlst� cC <br /> and the State sof California pertaining to` or- regulating well'constiruction:""W3ttiin FIHTDist & <br /> E after completion°-compwoxk" on-a-new.viiia;=l- will-furnish--the -San •Joaqui.n-Local.Realth-Dis.ttrict s <br /> WELL- DRILLERS REPORT of the well and notify them before putting the well in use'. <br /> The above' <br /> k information is true to the-best of my. knowledge and beliefF I .WILL CALL FOR A GROUT ENSPECTI(7N; <br /> PRIOR TO GROUTING ANDA AL INSPECTION. TITLE <br /> E SIDE --, <br /> SIGNED , <br /> D W: PLAN ON RS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> APPLICATION ACCEPTED BY �� <br /> A 00 <br /> ADDITIONAL COMMENTS: I FINAL INSPECTION <br /> PHASE 11 GRbUT INSPECTION '. tPHASE DATE � — <br /> 7 <br /> ` INSPECTION BY DATE INSPECTION BY <br /> AM . 2K`. <br /> r: E H 1426 Rev. 1^74 <br />