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SAN JOAQ01N LOCAL HEALTH DISTRICT <br /> FOF <br /> 1601 E. Hazelton Ave. , Stockton, Calif. E FFI� CE USE: 209 466--6781 <br /> Telephone: ( ) Permit Na. <br /> APPLICATION FOR FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Date Issued MAR 31976 <br /> (Complete in Triplicate)Joaquin permit to cor►struct , <br /> Application is"hereby made to td sSan ed. Thisoapplication cal Health Distmade inrict rcompliance witthSan Joaquin <br /> and /or install the work herein ; <br /> County Ordinance No. 1862 and thejRules e <br /> / an Reg a the San Joaquin <br /> 3 t CENSUS TRACT <br /> ' �r � ��� E: <br /> JOB ADDRESS/LOCATION /!� /�C <br /> Phone .°1------ `r <br /> Owner's Name <br /> k City <br /> Address / < a - I �� <br /> Phon <br /> License e �( �- <br /> Contractor's Name ►�J ���a <br /> DESTRUCTION <br /> DEEPEN / RECONDITION_/ <br /> TYPE OF WORK (Check) . NEW <br /> AL <br /> WELL <br /> INSTLATION /�J PUMP REPAIR / / PUMP REPLACEMENT <br /> 14 <br /> Other <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD _ PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> CONSTRUC'fION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Cab 1e Tool <br /> Dia. of Well Excavation <br /> 6 Industrial Dia. of Well Casing <br /> Drilled <br /> Domestic/privateDriven. Gauge of Casing <br /> Domestic/public .,:�,�.,..De �th--of—Grout--Seal-" -- <br /> _.Irrigation - -. s - _ ._.-Grave-l-Pack- P <br /> Rotary Type of Grout 1 <br /> Cathodic Protection Other Information <br /> �. <br /> Disposal Other � �_ Surface Seal Installed B <br /> i Geophysical. <br /> PUMP INSTALLATION: Contractor H.P. <br /> ' Type of Pump <br /> i - <br /> f c l <br /> PUMP REPLACEMENT A State Work Done - <br /> � <br /> PUMP .REPAIR: /% State Work Done <br /> t <br /> Approximate Depth <br /> DESFRUCTTON OF WELL: Well eter <br /> DescrlibemMaterial and Procedure <br /> oaqdili <br /> lth <br /> rict <br /> I hereby agree to COMP ly <br /> with all laws and regulations of the onstruc ian.LoWithinaFlFTEENtDAYS <br /> and the State of California pertaining to or regulating well. c <br /> after completion of my work on a new well, I,wi11 fforeshutt�ngatheowe�.lninouee..HeThehaboveDistrict <br /> WELL DRILLERS REPORT of the well and notify them be p <br /> information i true to the est of m knowledge and belief . I WILL CALL FOR A GROUT IN SPECTTOr <br /> 4PRIOR TO GRO NG AND AL INSP TIUN. TITLE <br /> SIGNED RAW PLOT PLAN ON REVERSE SIDE) <br /> E FOR DEPARTMENT USE ONLY <br /> r <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY`� <br /> sp <br /> ADAITIONAL COMMENTS: PHASE III/FINAL DATEEfI03 7 -- <br /> PHASE TT GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> 6/77 _ 2M <br />