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--- --_ter_.�:•:ti.�,--� � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. Hazelton Ave. , Stockton, <br /> Calif. <br /> FOR OFFICE USE: Telephone: .(209) 466-6781 <br /> APNo <br /> PLICATION FOR WELL CONSTRUCTION OR PUMF PERMIT Permit 9 <br /> Date Issued 7-2_�? <br /> THIS PERMIT EXPIRES I YEAR FROM .Dl�TE ISSUED V <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the. San Joaquin LocallicationDistmade inrict rco compliance with San Joaquin , <br /> and/or install the work herein described. . This app <br /> Count Ordinance No. 1.862 and the- Rules and. Regulations of h� 7 30�dn�S al Health District. <br /> �' <br /> CENSUS TRACT <br /> ,JOB ADDRESS/LOCATION VrC 0 <br /> Phone <br /> --------------- <br /> f Owner's Name a / <br /> City <br /> 1 Address <br /> License Phone <br /> Contractor's Name <br /> DESTRUCTION <br /> TYPE OF WORK (Check) : NEW WELL -g'. DEEPEN REFAIRCONDITIl�IJ P REPLACEMENT7J� 'h. <br /> pP INSTALLAT <br /> Other Q3Q C -T%�`.�1 <br /> ry � PIT PRIVY _ � <br /> DISTANCE TO NEAREST: SEPTIC TANK= Q SEWER LINES �v <br /> j SEWAGE DISPOSAL FIELDAI SSPOOL/SEEPAGE <?IT' ' OTHER <br /> �j. <br /> TYPE`OF WELL —CON STRUQ-WQNASPEC1FICATIONS <br /> � r <br /> USE r <br /> Industrial ? l � aWell Excav <br /> ble� Tool Dia• of ation <br /> INTENDED <br /> '"` Drilled Dia. of Well Casing <br /> Domestic/private' ^- iven Gauge of Casing <br /> + mestic/public --�- <br /> QI- r Gravel Pack Depth o£ Grout Seal <br /> Irr.gatian : <br /> Other L,Rotary <br /> Type o£ Grout E <br /> Other Other Information <br /> PUMP INSTALLATION: Contractors". <br /> H.P. <br /> t TYPe of Pump! i <br /> PUMP REPLACEMENT: / J StatedW6rk­Done <br /> f PUMP REPAIR. Stater`Work,)Done /R l <br /> r Approximate Depth <br /> DESTRUCTION OF-•TELL: Well Diame,I i - �-- tf�;"t i , <br /> Describe Material and Procedure w <br /> i <br /> I hereby agree to comply with all -laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining` to or regulating well construction. Within FIFTEEN DAYS <br /> ' I will furnish the San Joaquin Local Health District <br /> after completion of my work on a tAew well, <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' ' knowledge and belief. <br /> TITLE <br /> SIGNED <br /> SIGNED ' <br /> �-' i(D�tA.W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT U E ONLY <br /> pHASE_IM.�..--..�.----• - ' � '` '�� �'� DATE •" �`" <br /> APPLICATION ACCE D BY <br /> - <br /> ADD l.TIONAL COMMENTS: f t <br /> i- PHASE II GROUT INSPECTION <br /> PHASE IIIJFINAL INSPECTION <br /> r <br /> i INSPECTION BY - �� DATE s q SPECTYON, BYE; ',- O< DATE <br /> ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROOTING -AND FINS,INSPECTION. <br /> 4/72 1M <br /> E H 1426 <br /> t <br /> { <br />