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SAN JOAQ.UIN LOCAL HEALTH DISTRICT <br /> "Stockton, Calif. <br /> FOR OFFICE USE: 1601 E. Hazelton Aver ` 4bb-6781 ' <br /> Telephone: (209) IT Permit No. <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERM <br /> PLy 5 7 7 <br /> Date Issued <br /> THIS PERMIT :EXPIRES. 1 YE ' <br /> AR' FROM DATEISSUEDt 32�� r <br /> (Complete =In Triplicate) r _ Eft� = <br /> . ermit to construct <br /> 1 Health <br /> in Loca <br /> Application is hereby made tO {tdescribedaquThig.application istmade. inreo P1Qc �eHealthith San Joaquin <br /> District. <br /> C.onty.. work herein <br /> and/or install the .of the San-Joaquin <br /> Ordinance.No x,1862 and the.,Rules f and-Regulations <br /> CENSUS TRACTOP fk) <br /> S� <br /> ; $ .6DDiUrS-$/LOCATION €J <br /> ,Phone <br /> tri i ; <br /> •� II <br /> Owner's .Name <br /> y -^ City i <br /> Address - - <br /> 4, <br /> 1. <br /> _ _ - . .. Licensees ��- Fhone <br /> Contractor's Name <br /> 4 Checic)t"NEW;WELL"/ DE --pump CONDITIOI3 /-7-DESTRUCTION <br /> TYPE"OF WORK ( PUMP INSZYt1LLATTON I I P� REPAIR I I I P REPLAG mid . I? <br /> Other 1 <br /> t SEWER 11NES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK / CESSPOOL/SEEPAGE PIT / OCHER <br /> SEWAGE DISPO AL FIELD <br /> INTENDED USE TYPE OF WELL <br /> CONSTRi3CTI01 SPECIFICATIONS aNi <br /> Industrial ._fir. _. <br /> Cable Tool Dia. of Well Excavation - - <br /> Dia. of Well Casing <br /> r Domestic/private Drilled r <br /> Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> Gravel Pack <br /> Irrigation P <br /> Rotary Type of Grout <br /> f Other --�- Other �_. Other Information <br /> PUMP INSTALLATION: Contractor H.P. C <br /> ' Type of Pump <br /> k <br /> PUMP REPLACEMENT: State Work Done <br /> State Work Done <br /> PUMP REPAIR: h <br /> P <br /> t <br /> � APProximato Depth <br /> eESTRIFCTION'OF-WELL:' Well Diameter <br /> Describe Material and Procedure <br /> agree to comply with all laws and regulations of the San .Joaquin Local Health District <br /> h hereby g Within <br /> YS <br /> and the State of California pertaining to or will1furn she thecSantJoaquin.Local HealthrDistrict a <br /> after completion of my work on a new well, <br /> notify them before putting the well in use;. The above <br /> WELL DRILLERS REPORT of the well and <br /> . <br /> information i true to the bestgo my knowledge and belief. <br /> TITLE <br /> SIGNED (DRAW PLOT LAN ON REVERSE SIDE) <br /> FOR D PARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COM[+'IENTS: PHASE II FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> ' INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />