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s - ' ApSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFirOFFIGE USE: `1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. z�,�4eJ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE'ISSUED Date Issued <br /> f��- .s <br /> (Complete In Triplicate)- <br /> Application <br /> riplicate) <br />-A lication is hereby made to the San Joaquin Local Health Disttict for a permit to co struct <br /> Jaaquin�, <br /> PPSan <br /> ,and/or install the work-herein described. This application `is made in compliance <br /> County Ordinance No. 1862 and: the,Rules .and Regulations of the San Joaquin Local Health District. <br /> - <br /> '�- CEN SUS ,TRACT <br /> :JOB ADDRESS/LOCATION <br /> Phone <br /> 5 <br /> Owners V ams ; f <br /> ,QCity _ <br /> Address <br /> Itontractor'a Name <br /> Licensees h{ Phone <br /> Wt <br /> .� <br /> `TYFE`OF`WbRK (Check): NEW WELL / DEEPEN/� RECONDITION /T T DESTRUCTION �T� R <br /> 17 <br /> PUMP INSTALLATION / / PUMP REPAIR /�] PUMP REPLACEMENT . <br /> Other <br /> I! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . -= _ --PIT PRIVY. <br />'i SEWAGE DISPOSAL FIELD CESSPOOLI.$EEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' ' PUBLIC DOMESTIC WELL (� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation W11 !� <br /> Domestic. <br /> /private <br /> Drilled Di'a:` 'of Well Casing S AF <br /> Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation- Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protecion - Rotary Type of Grout <br /> azw <br /> Disposal Other Other Information <br /> ' Surface Seal Installed B <br /> .Geophysical <br /> - . ---_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` H.P. _ <br /> PUMP REPLACEMENT: / S Cate Work Done <br /> .,-. <br /> PUMP '.REPAIRStateM Work Done <br /> Approximate Depth - <br /> �ESTRNFCTION OF WELL: Wa11 Diameter <br /> Land Material and Procedure 3 <br /> hereby a toc p y with all laws and regulations of the San Joaquin"-Local.-Health District <br /> Y gres <br /> I <br /> and the State of California pertaining to or regulating well cans'ruction. =°~Withiii7—ft-EEN DAYS <br /> after completion 'Of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting-the.-well in use.• The above <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR' 'GROUT INSPECTION <br /> PRIOR TOG UTING-AND A INAL I43FEGUM. 12 TITLE <br /> l SIGNED <br /> ��kDRAWPLOT LAN ON RSE SIDE) <br /> FOR DEPARTMENT. E-ONLY _- <br /> PHASE I <br /> APPLICATION--ACCEPTED-BY " <br /> ADDITIONAL COMMENTS: E .I IAISPECTI N <br /> P G UT INSPECTION �� INSPECTIO DATE '^7S <br /> INSPECTION BY DATE <br /> i - <br /> } -7 4 2M <br /> 9 E H 1426,:.-Rev. 1-74 - <br />