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SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOE OFFICE USE: i () <br /> Telephone : (209) 466-6781 permit No. �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to: the San JoaquThisin Local <br /> p1, tion istmade inrict rcompliancea permit twico San uJoaquin <br /> and/or install the work herein described. p y <br /> County Ordinance No. 2 and the- Rules and Re[gulat' n of the San-Joaquin Local alth District. <br /> ' S CENSUS RACT ; <br /> JOB ADDRESS/LOCATIO <br /> P ' Ph- e — <br /> Owner's Name <br /> City � <br /> Address3!� <br /> License, #Z-S hone! <br /> Contractor's Name 0ti. <br /> STRUCTION <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN I / RECONDITION <br /> / pUMPEREPLACEMENT�I <br /> PUMP INSTALLATION / / PUS: <br /> Other / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CCS POOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> — <br /> PROPERTY LINE - PRIVATE DOMESTI E�ELLCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable TooTDia. of Well ExcavatidnDomestic/private Drilledof Welt CasingDomestic/publicDrivene of Casings IrrigationGravel Pah ;,of Grou��aI <br /> ' y � _T eof Grout <br /> Cathodic Protecton R° Other <br /> Information <br /> Disposal Other edB <br /> Geophysical Y Surface Seal install � _. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 3 <br /> A <br /> PUMP REPLACEMENT: / / Stat Work Done <br /> S ate Wor-k-Done ' _ <br /> PUMP '.REPAIR: / - <br /> 't <br /> Approximate Depth �- <br /> DESTRUCTION OF WELL: Wel Diameter . <br /> Describe Material and Procedure ` <br /> the San Joaquin <br /> herebyagree to comply with all' laws and regulations of n Local Health District <br /> I g <br /> and the State of CaliforniAYS <br /> a per-tairting` to `t willlfurnii shethecSantJoaquin'Local h ealthTDistEEN rict <br /> of m work on a new 'well,., above <br /> i after completionyore . <br /> WELL DRILLERS REPORT of the well nknowledgemandfbeliefti WILL WALL .ln GROTheINSPECTION <br /> information is true to the best y <br /> PRIOR TO G TING AND A FIN INSPECTION:"""i� t T TLE <br /> SIGNED (DRAW PLOT PLAN ON EVERS ID <br /> FOR DEPART NT USE L • <br /> PHASE <br /> /'- DATE <br /> I 4�l�sD�r�, <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p E III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION. INSPECTION ICDATE <br /> k INSPECTION BY DATE <br /> 6/77 2M <br />