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AN JOAQUIN LOUL AALTH DISTRICT <br /> FO :'OFFICE USE. Ol E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> k ICATION FOR WELD CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � l31! -?7 <br /> THIS PERMIT EXP .:I <br /> EXPIRES 1 YEAR FROM DATESSUED pate Issued � <br /> (Complete In Triplicate) ?f"— Oda--tc7 <br /> Applica'ion ia'hereby made to the San Joaquin Local health District for ik perm t to construct <br /> and/or install the work herein described. This application is :Wade in compliance with San Joaquir <br /> Cop �00,dinac,e nNo. 1662 and the Rules and Regulations of the , n Joaquin Local Health ,District. <br />� � ��,�JOBsOCATION e- ,( V�`'l�, CENSUS TRACT <br /> - <br />° Owner's Namef .,!!rl -- - - - Phone ' <br /> 4 <br /> I •Address City <br /> Contractor's Name / { l License 'hone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN ' 7 RECONDITION /7 DESTRUCTION /-7 ! W <br /> k PUMP INSTALLATION 'S PUMP REPAIR-,/ PU REPLACEMENT r7 <br /> Other / / F <br /> + DISTANCE TO NEAREST: SEPTIC TANK Q�f..SEWER LINES,__Z&YIT PRIVY <br /> SEWAGE DISPOSAL FIELD ¢,CES POOL SEEPAGE'P.IT706 706 ,K-OTHER <br /> PROPERTY LINE/OPTRRIVATE -DOMESTIC WELL" "= PUBLIC DOMESTIC WELL 9'_ <br /> INTENDED USE TYPE OF WELL ,--' CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool 'Dia. of Well- Excavation�. <br /> Domestic/private Drilled Dia. of Well'Casing <br /> . Domestic/public !` ' Driven �, Gauge of Casing'' <br /> Irrigation '" Gravel Pack,. -' Depth of �Grout Seal <br /> Cathodic Protection' Rotary Type of .Grout �. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Ins alled 'B <br /> PUMP INSTALLATION- Contractor <br /> 1. Type of Pump H..P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> I I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dis tri <br /> r and the State •of California pertaining to or regulating well'-construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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- my.-knowl dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED ITLE <br /> W PLO P ON REVERSE SIDE <br /> FOR DE ARTMENT USE ONLY ; <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: (J <br /> PRAS-E 11 GROUT INSPECT ON PHASE.. I NAL INSPECTION <br /> ' INSPECTION BY DATE, INSPECTION BY `! V)0 DATE <br /> E H 1426 Rev. 1-74 � :� � -_ _1 - ?x/75 2M_ v' <br />