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t,, SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> Ave. , Stockton, Calif. <br /> FOE OFFICE USE: _ 1601 E. Hazelton2Cg �66-678]. <br /> Telephone; { ) Permit No. . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 77` 3)0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date <br /> issued , ' <br /> • (Complete In Triplicate) pe <br /> to construct <br /> This application is made in compliance with SanDistrict.Joaquin ' <br /> A lication is,hereby made tv `the San JoaquTh LvcPP Health District for a p th <br /> PP uin Local Heal <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin <br /> CENSUS TRACT 4 <br /> •.JOB ADDRESS/LOCATION Phone <br /> Owner's Name City <br /> �--�� <br /> Address <br /> License Phone-5 <br /> l 'Contractor's Name .- <br /> T EEPEN / J RECONDITION I I DESTRUCTION I�7 <br /> " .TYPE OF WORK (Check) NEW WELL J(� D Pip REPAIR I I PUMP REPLACEMENT I� _ <br /> p� INSTALLATION /le/� r <br /> Other. / / <br /> PIT PRIVY <br /> DISTANCE TO I3EAREST: SEPTIC TANK, <br /> SEWERLINE _ OTHER \ <br /> SEWAGE DISPOSAL FIELD ___ CESSPOOL/SEEPAGE PIT r� <br /> PUBLIC DOMESTIC WELL <br /> PROPERTY LIME f= PRIVATF750MESTIC WELL CONSTRUCTION SPECIFICATIONS y <br /> INTENDED USE TYPE OF'.WELL ! <br /> —gable Tool t� pia. of Well Excavation <br /> Industrial Dia.- of Well,Casing <br /> J Drilled <br /> Domestic/private �. .. Gauge of Casing <br /> _t--D <br /> ' �' : . Driven , �- Q <br /> f -tic/Pu Gravel Pack ' Depth of Grout Seal S <br /> Irrigation '�-=-�"wRvtary t Type of Grout <br /> t Cathodic Protection ��` Other Information: <br /> ". ' Other _ <br /> ----- c ! Surface Seal Installed <br /> B = <br /> G <br /> —Disposal Geophysical Ni =, <br /> M per`^,INSTALLATION: Contractor H.P. <br /> x Type of Pump <br /> g <br /> F. J J. State Work Done ti <br /> PUMP REPLACEMENT: <br /> PUMP .REPAIR: / / State Work Done <br /> Approximate Depth ��. <br /> F DESTRUCTION OF WELL: Well Diameter r <br /> Describe Material and Procedure <br /> rict <br /> r comply with all laws and regulations of the San <br /> trucgtion.uin Lowithincal aFIF'TEENtDAYS <br /> I hereby agree. to p Y <br /> and the State of California pertaining l or regulating wel CO Joaquin Local Health District <br /> after completion of my work on a new well, I will furnish the San Jowe <br /> WELL DRILLERS REPORT of the well and notify them before putting the well O use. The above <br /> information is true to the-best. of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO. TING AND A FINAL INSPECTI TITLE f <br /> SIGNED RAW PL 'I' PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY �� / / <br /> DATE `ti' 2' <br /> PHASE I0lr <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: r PHASE III/FINAL INSPECTION <br /> PHASE II GR T INSPECTION FATE INSPECTION BY DATE /�+ `4-7 7 <br /> � DATE S� - <br /> INSPECTION BY 3/75 2M <br /> z u 91.9A RPV. 1-74 <br />