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WW'"""'. ;i SAN JOAQUIN LOCATE HEALTH DISTRICT <br /> FOh OFFICE USE: ij 1601 E. Hazelton Ave. , Stockton, Calif. /f <br /> - i! Telephone: (209) 466-6781 permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San .Toaquin Local <br /> District <br /> for <br /> twithSan <br /> construct <br /> licationismade incompliance Joaquin <br /> This a � <br /> and/or install the work,herein described. PP <br /> � <br /> nd Regulations of the San Joaquin Local Health District. <br /> County Ordinance No, 1862 and the R <br /> r ` 5 �r CENSUS TRACT ' . <br /> JOB ADDRESS/LOCATION <br /> Phone _qs`f R Z <br /> Owner's Name c Uel` <br /> city p1ctn+c4c, <br /> Address <br /> License # ^ Phone <br /> Contractor's Name <br /> li <br /> r TYPE OF WORK (Check) : i:NEW WELL I I DEEPEN ppECROEPAIRI/ NII PEJMpEREpLACEMENT�I�T <br /> PUMP INSTALLATION <br /> ��Other <br /> � PIT PRIVY _ t"f <br /> DISTANCE-10 NEAREST: SEPTIC TANK SEWER LINES OTHER <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> PUBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> ' Industrial �+ `� Cable Tool Dia. of Well Excavation <br /> Domestic/private, Drilled Dia. of Well Casing <br /> Domestic/public ' <br /> Driven Gauge of Casing <br /> Irrigation '� Gravel Pack Depth of Grout Seal <br /> Type of Grout. <br /> Cathodic Protection Rotary ether Information " <br /> Disposal Other <br /> Geophysical '" '!• <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: �1 Contractor ✓)� n�`� ;�„ `"� H.P. <br /> �I Type of Pump pct`s l <br /> PUMP REPLACEMENT: ;9 / / State. Work Done <br /> �ry <br /> .i <br /> PUMP REPAIR: / / State Work Done <br /> �i Approximate Depth , <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Describe Material and Procedure <br /> cal He <br /> I hereby agree to comply with all laws and oregelaing well'construction.LoWithinaFIFTEENtDAYS <br /> and the State of California pertaining to g <br /> after completion of my work on a new well,f Iwill <br /> beforefurnish <br /> puttingatheowellnin use.HeTheh hover ct <br /> WELL DRILLERS REPORTfof the well and notify them <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND, A FINAL INSPECTION. TITLE �� <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE . <br /> APPLICATION ACCEPTED�BY <br /> ADDITIONAL COMMENTS: pHASE I/FINAL INSPECTION <br /> PRASE II GROUT INSP CTION INSPECTION BY DATE Z 7 <br /> INSPECTION BY ! DATE <br /> 1 /77 CO2M <br /> 1-74 <br />