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646 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,!55- ,5->7 �0 <br /> h <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 102 and the Rules and Regulations of the San Joaquin Local health District. <br /> ADDRESSr- 1164 <br /> a '� c �� !�� CEN <br /> JOB SUS TRACT <br /> Y Phone <br /> Owner's Name <br /> City <br /> Address / 3 a <br /> License <br /> 37 3 Phone 3 <br /> Contractor s Name <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN %I RECONDITION / / DESTRUCTION fT <br /> PUMP INSTALLATION/ I PUMP REPAIR �/ PUMP REPLACEMENT 1-7 <br /> Other / / t <br /> 1 � <br /> DISTANCE TO NEAREST: SEPTIC TANK_. , ` SEWER LINES ; PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> _ SEWA.G .P PS:AI� TLD__ - <br /> .I PROPERTY LINE - PRIVATE DOMESTIC PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j - Cable Tool Dia. jof Well Excavation <br /> Domestic/private Drilled Dia. lof Well Casing q <br /> _ Domestic/public <br /> Driven Gaug� of Casing <br /> Irrigation k Gravel Pack Depth of Grout Seal <br /> ' Cathodic Pro ection Rotary Type{of Grout <br /> 1 Other Othe Information <br /> Disposal �--- Surflee Seal Installed B : <br /> GeophyrsAca.l , 1 <br /> PUMP INSTALLATION Contractor H.P. j <br /> Type: of Pump s f <br /> � PUMP REPLACEMENT: i `��7��tate'Wo��k"Do�e��.� _ <br /> ePUMP REPAIR: 4 State Work Done , ' <br /> } Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations bf-the San Joaquin Local Health District <br /> and the State of California pertaining to- or regulating, we'll'construction. Within FIFTEEN DAYS <br /> after completion of work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPdR'T of the well and notify them beforet[ putting the well in use. The above <br /> nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> information is true to the best of my k <br /> PRIOR TO GROUTI AND A FIN INSPECT N. <br /> SIGNED i TITLE <br /> i DRAW PL T PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENTS USE ONLY <br /> a <br /> PHASE I I DATE a <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: ; ' ! PRASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTI DATE <br /> INSPECTION BY DATE INSPECTION BY , <br /> 3/76 2M <br /> ' F H 1426 Rev. 1-74 <br />