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/ W-1W <br /> ✓`x'' Vv`� SAN JOAQUIN LOCAL HEALTH DISTRICT 50--' <br /> FOB OF'F'ICE USE: :1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209,) 466-6781 <br /> APPLICATION FOR WELL CONSii6CTION OR PUMP PERMIT ermit No. <br /> 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date• Isaued �_}a <br /> 1� i (Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. Ut§2 and the R lee an gulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION err p <br /> . ,. � I frJ e c (-4' CENSUS TRACT I <br /> Owner's Name % <br /> "' y' '` Phone�� .• <br /> f rr, <br /> Address i - -�/ f ,� <br /> f� � City ' r r <br /> Contractor's Name, <br /> License {� /7� hon <br /> TYPE OF WORK (Check): NEW WELL.i"7 DE9PEN '/_T RECONDITION I T DESTRUCTION <br /> PUMP INSTALLATION /� PUMP REPAIR /� PUMP REPLACEMENT /7 �-- <br /> _ w Other <br /> ,.DISTANCE TO NEAREST: SEPTIC TANKSEWER LINESFIT PRIVY `J <br /> SEWAGE DISPOSAL FIELDq_d< CESSPOOL/SEEPAGE F'IT OTHER �''� <br /> F PROPERTY LINE - PRIVATE DOMESTIC WELtQ PUBLIC DOMESTIC WELL <br /> r INTENDED USE TYPE OF WELL CONSTRUCTION <br /> .SPECIFICATIONS <br /> f -�--� �Industrial `.��. s ':'�' Cablel Tool Dia., of Well Excavation <br /> /private i Drilled ;D�a'. of Well Casing " <br /> Domestic/public i Driven eGauge of Casing P- - <br /> Irrigation ± Gravel PackDepth of Grout Seal <br /> Cathodic Protection r 'Rotary Type of Grout <br /> Disposal Other' �, � �.`.k r''= , tion <br /> Other Informs <br /> Geophysical --------�~ <br /> Surfac Seal Installed B <br /> : <br /> PUMP INSTALLATION: Contractor ��✓ � - �� <br /> _-Type•-of,Pump-� ..6,, , <br /> A.P. <br /> Ize <br /> PUMP REPLACEMENT: <br /> '.L-/ ,-,State Work. Done =. <br /> PUMP '.REPAIR:.. . -• -,i�, <br /> - /7--State Work .Donee <br /> # - <br /> r <br /> DESTRUCTION OF WELL �'kTe].11 Diameter � ���"�' ..� � _ � $ <br /> Approximate Depth <br /> Desctibe, Material and` Procedure <br /> I hereby agree to comply withi all laws and regulations of-`the San Joaquin Local Health District <br /> and the State of California pertaining tb,,ortegul'ating,.well''construction. With;3n FIFTEEN DAYS <br /> after completion of my work ion a new weld, I,!.w 'furnishAhe San Joaquin LocA-.health District a <br /> WELL DRILLERS .REPO RT of the well and notify them beTore;.putting.. the..weW'in.use 1. The above <br /> information is true to- the•best -of. my.knowledge/and!belief:.y I WILL CALV FOR A GROUT INSPECTION <br /> PRIOR GROUT NGI D FINAL ECTiON'. <br /> SIGNS TITLE i <br /> DRAW PLOT PLAN'40N REVERSE !SIDE <br /> 4 <br /> PHASES € FOR DEPARTMENT USE ONLY <br /> .. <br /> APPLICATIONr,ACCEPTED.BY d <br /> ADDITIONAL COMMENTS " "._ -DATE 7,2 <br /> At <br /> PHASE IGRO ;INSPECTION s P I <br /> IIF AL INSPECTION <br /> INSPECTION BY DATE �-. : �. .r..,,,�INSPLCTION-B DATE 3 f <br /> /�6 <br /> E H 1426 Rev. 1-74 <br />