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I. <br /> SAN 30AQUIl3 LOCAL HEALTHDISTRCa1if. <br /> ►" Stockton, <br /> 1601 E. Hazelton Av209) 466-6781 Permit No. � <br /> FOF� OFFICE USE: Telephone: ( PERMIT <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA Date Issued <br /> MIRES 1 YEAR FROM DATE ISSUED <br /> THIS PERMIT licate) <br /> (Complete In Trip perm' t• construct <br /> made in compliance with San Joaquin <br /> made to the San Joaquin Loa plication is <br /> strace for a P LacaI Health District. <br /> Application is laereby This PP <br /> and/ 862 and the Rules and Regulations o£ the San Joaquin <br /> or install the work herein described. <br /> County Ordinance No. 1 f CENSUS TRACT <br /> E G TO►1`�- oP <br /> JOB ADDRESS/LOCATION Phone 1 <br /> Owner's Name <br /> City CL <br /> S1hone <br /> Address 51 License <br /> Contractors Name L a u rl c l <br /> 4 DESTRUCTION /7 <br /> DEEPEN !1 jol <br /> RECONDITION 1 <br /> NEW WELL / PUMP REPLACEMENT I T <br /> TYPE OF WORK (Check): PUMP INSTALLATION / P PAIR I:I <br /> t other �/ <br /> PIT PRIVY l� <br /> SEPTIC TANK � SEWER LINES �-- OTHER �� \ <br /> DISTANCE TO NEAREST CESSPOOL/SEEPAGE PIT <br /> t SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS ` <br /> INTENDED USE TYPE OF WELL Dia. of Well Excavation r��l3 <br /> € Industrial Cable Toal <br /> Drilled Dia. of Well Casing t, <br /> Domestic/private Dairy �� Gauge of Casing c 164 s <br /> ublic �_ Driven Depth of Grout Seal <br /> Domestic/p —L--1 <br /> � Gravel Pack P CPm�� <br /> Irrigation � Rotary Type of Grout P <br /> G �~ Cathodic Protection Other _ Other Information c �� <br /> Disposal ---� Surface Seal Installed B = <br /> i GeophysicalContY <br /> pUW INSTALLATION: TYPer°ftor Pump <br /> pUNp REPLACEMENT: / <br /> State Work Done <br /> pUMP REPAIR: /% State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL_:, .W1 iometer <br /> Descr-be Material and Procedure { <br /> y e <br /> 1112 <br /> ' I hereby agree tn=compijWith all laws and reg <br /> ulatio o the San Joaquin Local Health District <br /> State of California pertaining to or regulating well''coustruction. Within FIFTEEN DAY. <br /> F and the I will furnish the San Joaquin Local Health District <br /> above <br /> after completion of my work on a new well, the well -in <br /> WELL DRILLERS REPORT of the well and notify andem fbeliefore ttiI WILL CALL FOR AeGROUT eINSPECTIO1 <br /> information t Of. my <br /> PRIOR TO GROUTING AND° the A -FINALSINSPECTIONknowledge <br /> � TITLE <br /> SIGNED D PITT PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �•� DATE <br /> APPLICATION ACCEPTED BY f- <br /> ADDITIONAL COMMENDS: <br /> ' �� -=� PHAS III/ NAL INSPECTION <br /> P ff NSPECTION DATE <br /> DATE INSPECTION BY <br /> € INSPECTION BY 3,76 2M <br /> R H 1426 Rev. 1-74 <br />