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SAN JOA UIN LOCAL HEALTH <br /> Q Stockton Calif- <br /> -Of, <br /> alif. <br />_ <br /> FOP .�l'FICE USE �- 1601 E. Hazelton Ave. , <br /> > <br /> Telephone : (209) 466--6781T Permit No. ��__ iu <br /> APPLICATION FOR WELL CONSTRUCTION OR P,NP PERMIT <br /> Date <br /> THIS <br /> Iss� n.d�� ✓ , <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ���--- (Complete In Triplicate) ermit to construct. <br /> application is hereby made to the San Joaquin LocalHeahDistrict made inrcompli_ance with San Joaquin <br /> and/or install the work herein described. This application <br /> iounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION 1A•t����.���r�r - -- -_�--_��. -� <br /> Owner's Name � ' -'�` <br /> 12 Phone <br /> City <br /> Address San Joa n CU..,P C 0. a e �� �©3J Phone '3 -bri <br /> '` � <br /> Lic.. -s <br /> Contractor' s Name Division <br /> 711 N. $clrn:nP -- <br /> _..__.��. q DE,S`TRUCTION <br /> TYPE OF WORK (Check) : NEW WELL { � DEEPEN / / RECONDITI.iJS, � PUMP REPLACEMENT <br /> PUMP INSTALLA"£ION PUMP REPAIR /lifT � <br /> Other NES P <br /> _- <br /> �__--a�PTT ?�-I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PRIVY PIT OTHER . <br /> SEWAGE DISPOSAL FIELD - <br /> pjtOPERTY LINL? - PRIVATE DOMFS'I`IC PUBLIC LiOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL - -- <br /> Cable Tool Dia. of Well Excavation <br /> Industrial -- <br /> Domestic/private - Drilled Dia. of Well Casing <br /> Driven Gauge of Casing --- - -- <br /> Domestic/public ��__. - 'A <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> Type of Grout _ <br /> Cathodic Protection Rotary Oder Information <br /> Disposal - Other — { <br /> Surface Sea.1 .Installed I3 <br /> Geophysical _-� -__- � <br /> PUMP INSTALLATION: Contractor - -------- -- -- -� -. <br /> Type of Pump <br /> S <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP REPAIR: / <br /> State Work Done <br /> _ Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter -------- <br /> Describe Material and Procedure <br /> La <br /> I hereby agree to comply with a7.1 laws and regulations of the <br /> cSan <br /> Joa uin. WithiaDistrict <br /> Within FIFTEENDAYS <br /> and the State of California pertaining to or regulating well <br /> after completion of my work on a new well, I will <br /> bfurnish <br /> efore putthe <br /> San <br /> Joaquin <br /> e welliLocal <br /> useHealth <br /> The District a <br /> hove <br /> WELL DRILLERS REPORT of the well and notify them <br /> f. I WILL CALLFGROUT <br /> CTION <br /> information is true to the best of my knowledge and belie <br /> tAQa? _._.,_.SPF_....---. <br /> — 39 o Ea°�83j CQ. <br /> PRIOR TO GROU D A FINi11 I T TITLE <br /> SIGNED <br /> -- (DRAW PLOT PLAN ON REVERSE SIDE) y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE � y^ <br /> APPLICATION ACCEPTED BY q Cf - ----- -- -'-`-- <br /> ADDITIONAL COMMENTS: PHASE IjI/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE _ r <br /> /7 _ 21A <br />