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j/ FOS OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT q <br /> 1601 E. Hazelton Ave. ,. Stockton Calif. <br /> Telephone: (2 3)^''46-6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit Na. <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r ( Date Issued? <br /> Application is hereby made to the San o�uineLo al Hec:lth District for a <br /> and/or install the work herein described. Permit <br /> County Ordinance No.. 1862 and the Rules andThis RegulatinOPPttafnthe SaneJoaquin is Incompliance�withnSanuJonquirn <br /> it ' `` nsquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> Owner's Name I` <br /> CENSUS TRACT <br /> Phone 44.,_ <br /> Address Pho <br /> _ � <br /> City .. - <br /> Cantractor's'Name 1 <br /> . License # Phone L/G, 3 -7 qJ <br /> TYPE OF'.WORK_ (Check): NEW WELL <br /> / T DEEPEN -/-T RECONDITION /? DESTRUCTION <br /> .. ,. PUMP INSTALLATION / / PUMP REPAIR <br /> / <br /> Other / �? P REPLACEMENT ` f <br /> DISTANCE TON 1 <br /> EAREST. SEPTIC TANK <br /> SEWAGE DISPOSAL FIE HEWER LINES _ PIT PRIVY~ <br /> PROPERTY- LINE -- PRIVATE DOMESTIC WELL EEPAp E PIT OTHER _ <br /> INTENDED USE T7rE OF WELL PUBLIC DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> _ Domestic/private -- Cable Tool Dia. of We11 Excavation <br /> Domestic/public Drilled Dia. of Well Casing � { <br /> Driven' <br /> Irrigations Gravel Pack - Gauge of Casing <br /> Cathodic Protection Rotary of Grout Seal - <br /> ,_,^,.Disposal. : - —�� Rotary Type of Grout <br /> Geophysical , ! Other r Other Information <br /> ! Surface Seal Installed 'B <br />?UMP INSTALLATION:, Contractor <br /> _ �. ..: ,.Type .of Pump <br /> g? €. - � . H.P. <br />'UMP REPLACEMENT;"n . ------- <br /> E/ State Work. Do e <br /> :REPAIR: '*,.State <br /> _. / Work Done <br /> ES°TRION OF WELL; Well Diameter <br /> Approxi.ma a Depth &© r <br /> Describe Material and Procedure <br /> 1, Ccr <br /> herebyares to com l with all laws and regulations o the Sa Qoaquin Local H R.R <br /> S p yr �yyti <br /> ad the State of California pertaining to or regulating well -construction. sal h Dct <br /> Eter completion of my work on a new well, I will furnish the .San Joaquin LocalHealthDistrict a <br /> ELL DRILLERS REPORT .of'the well and notify them before putting the.-well. in use.... The above <br /> iformation is true tn-�he,best .'of. my..knowled a and belief. <br />,TOR UTiNG AND A F AL INSPECTION. g I WILL CALL FDR' A GROUT INSPECTION <br /> LGNE ' <br /> TITLE x <br /> (ARA PLOT PLAN ON REVERSE SIDE <br /> ASE F R DEPARTI,NT USE ONLY <br />'PLICATION' ACCEPTED BY - }' '` �` j <br /> 7 <br /> DITIONAL /O <br /> KWS . <br /> DATE <br /> PHASE II I N t <br /> SPECTION BY D P S I I FINAL INSPECTION rf <br /> INSPECTION BY DATE - <br /> E H 1426 - <br /> Rev. 1-74 - - <br />