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S <br /> FOP,rOFFICE USE: AN JOAQUIN'LOCAL,HEALTH DISTRICT <br /> 1601 E. Hazelton Ave.=, :Stockton, Calif. --- <br /> Telephone:t.I(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP -PERMIT Permit No. <br /> `` THIS PER.MIT'EXPIRES 1 YEAR FROM DATE. ISSUED <br /> �II " (Complete In rTripi ic,a�e) Date Issued <br /> Appli6dtian Is hereby made to the San Joaquin Local. Health District for a g�ermit to Construct <br /> and/or install the work herein described. This„application is made in :compliance with st <br /> County Ordinance 'No.: 1862 and the Rules and Regulatiorns. ®f the "San Joaquin Local He nstruct <br /> San Joaquin <br /> JOB ADDRESS/LOCATION I Health District. <br /> S S <br /> Owner ps 'Name �cL - �: CENSUS TRACT ---�..-. <br /> iM Phone <br /> Address 3 ,�c3 ---.. .._. <br /> -R,4�; , <br /> I' 4ri{ems.:, i <br /> Contractor's Name ;{ 1 <br /> ' City <br /> jl <br /> 1w n c e �c� ; . . License # <br /> Phone <br /> TYPE OF:WORK (Cheek): NEW WELL /? DEEPEN /_7 RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION /R/ PUMP REPAIR / / PUMP REPLACII�NT <br /> ! <br /> Other / / /-' <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> ------------ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 4 <br /> INTENDED USE TYPE OF WELL LL�� <br /> „^ Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic -- Cable Tool Dia. of Well Excavation ` <br /> /private ��_ Drilled Dia. o€ Well Casing { <br /> __�__:_Domestic f publics- � . <br /> . Driven- r Gauge-of�Casing <br /> Irrigation _ l. <br /> Cathodic Pr_otectiony f Rotor �Gravel Pack Depth of Grout Sea (•t1 <br /> Disposal P _____w`RotarType of Grout O <br />_,,,,GeophysicalOther Information <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor ' _ <br /> eL <br /> Type of Pump <br /> dM. H•P• C <br /> PUMP REPLACEMENT: ---- <br /> /./ State Work Done <br /> u� <br /> PUMP :REPAIR: /? State Work Done _ <br /> ESTRUCTION OF WELL: Well Diameter ... <br /> De9cribe Material-and Procedure Approximate Depth <br /> I hereby agree to comply Witt all laws and -regulationsof <br /> after completion of my the San Joaquin Local HealthDis <br /> and the State of California pertaining to or01: <br /> well construction. Within FIFTEENtric <br /> BELL DRILLERS REPORT owork on a new well, I will, furnish the San Joaquin Local Health District a <br /> f the well and notify ,them before <br /> g-the- well in use,. The <br /> ln€ormatiOn is true to the`-best of. above <br /> and .belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO G OUTING AND A FINAL INSPECTION.. <br /> iIGNED 1 n„` w <br /> TITLE <br /> (DRAW PLOT PLAN OR REVERSE SIDE i <br />'RASEZ ,., I u FOR.DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: i�, DATE ��3.77 <br /> PHASE II GROUT INSPECTION - f t <br /> NSPECTION BY :11 DATE P III INAL INSPECT N C <br /> INSPECTION BY DATE <br /> ,E�H 1426� � Rev. <br /> 74 1 <br /> I <br />