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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif- <br /> 1601 OFFICE USE: Telephone: (209) 466-6781 76-./7/ F' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> Date issued 6.- -7d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l .�l^QF3 4 <br /> (Complete In Triplicate) emit to construct <br /> 1 Health Application is hereby made tol the San Joaquin Loca application istmade inrict rco compliance with San joa ctin' <br /> and/or install the work herein describe Mations of the San Joaquin Local Health <br /> County Ordinance No. 1$ 2 and the Rules and R <br /> U t qt-2-76 . 41C,4-14 <br /> r 3 ' C �I1J CENSUS TRACT <br /> JOB ADDRESS/LOCATIO w <br /> Phone <br /> Owner's Name <br /> City <br /> Address i isSl 7-7 <br /> O , License # ^�^ Phone <br /> � <br /> Contractor's Dame M i <br /> t <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN / / <br /> RECONDITION / DESTRUCTION /? <br /> T <br /> PUMP INSTALLATION PUMP REPAIR I' P REPLACEMENT l <br /> Other <br /> i� <br /> SEWER LINES PIT PRIVY <br /> _ <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS ry <br /> INTENDED USE Dia. of We11 Excavation <br /> Industrial l Cable Tool <br /> 'l Drilled Dia. of Well Casing <br /> Domestic/private --�`r Driven Gauge of Casing <br /> Domestic/publics Depth of Grout Seal <br /> Irrigation Gravel Pack P <br /> RaType of Grout <br /> Rotary Cathodic Protection' other <br /> Lay r Other Information <br /> Disposal Surface Seal Installed B : <br /> �. Geophysical k <br /> PUMP INSTALLATION: Contractor H.P. <br /> Types` of Pump - <br /> 4 PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / /,; State Work Done <br /> Approximate Depth �,�_„� <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> t <br /> T hereby agree to comply with all laws odoregelations of ulating wellEconstrucSan tion.Local <br /> WithHnaFIFTEENDistrict <br /> DA'YS <br /> i and the State of California pertaining g <br /> after completion of my work on a new well, Ithemlbeforefurnish <br /> puttingSan <br /> theoWellninouse.HeTheh bover ct <br /> WELL DRILLERS REPORT of the well and notify <br /> information is true to the best of my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> M. PRIOR TO G UTING AND AFIN INSPECTION. TITLE <br /> SIGNED <br /> A W..pLpT PLAN 'ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> a <br /> PHASE I DATE _� - <br /> YPLICATION ACCEPTE ` <br /> ADDITIONAL COMMENTS: 1 PHASE III/FINAL INgpECTIO-7^ 7 <br /> PHASE II GROUT INSPECTION INSPECTION BY � DATE —�— <br /> INSPECTION BY DATE - <br /> 3/7b 2M <br /> ,AIA ua.r_ 1--74 _ _ <br />