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ra " ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF'OFF t', USE: 1601 Stockton Calif. <br /> 1601 E. Hazelton Ave. , <br /> Telephone: (209) 466-6781 Permit No. <br /> 0 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued Y-e��Of <br /> (Complete In Triplicate) ermit to construct <br /> Application is hereby made to the San Joaquin Local Health District for a p with <br /> and/or install the work herein described. This application is maneJoaquinpLocal HealthSDistrict. <br /> County Ordinance No. 1862 and the Rules and Regulations <br /> of theJOB ADDRESS/LOCATION 'S SD � � G <br /> CENSUS TRACT <br /> " Phone -- <br /> owner's Name �- ��>� g� '', z. <br /> /� City •. ' <br /> Address TV A ��3 �x - <br /> �� 3-?y(phone <br /> License k <br /> Contractor's Name <br /> RECONDITION / DESTRUCTION <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ pip REPLACEMENT <br /> PUMP INSTALLATION / / PUMP REPAIR /1Q <br /> Other <br /> VY <br /> DISTANCE TO NEARESTSEWER LINES PIT PRI <br /> : SEPTIC TANK — OTHER ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ — PUBLIC DOMESTIC WELL 1- <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS >' <br /> INTENDED USE Dia, of Well Excavation <br /> Industrial Cable Tool <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> X_ Irrigation Gravel Pack p <br /> T e of Grout <br /> Cathodic Protection Rotary <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By.: <br /> PUMP INSTALLATION: Contractor H.V. � Q <br /> Type of Pump w r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / C/ State Work Done u <br /> DESTRUCTION OF WELL: DescrDbemApproximate Depth <br /> Material and Procedure �_.-. <br /> San <br /> lth <br /> I hereby agree to comply with all laws and regelations ulatingowelleconstruction.Local <br /> With�inaFIFTEENDistrict <br /> DAYS <br /> and the State of California pertaining to or g <br /> after completion of my work on a new well, I will <br /> bfurnish <br /> puttingatheowell the Sn ninouse.xeThe District <br /> above <br /> WELL DRILLERS REPORT of the well and notify t <br /> hem fore information is true to the best of m kno e d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP N• ITLE <br /> SIGNED <br /> (D W PLO PLAN ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 2 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: p S I INAL INSPECTI N 4 <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE C� <br /> INSPECTION BY DATE <br /> n/77 _ 2M <br /> V u 1L91; RPV. - 1-74 <br />