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�P SAN JOAQUIN LOCAL HEALTH DISTRICT T ------A. <br /> FOA rOF'I�'ICE US E; 7k 1601 E. Hazelton Ave., Stockton, Calif. <br /> a p <br /> Tele hone: <br /> APPLICATION FOR WELL CONSTRUCT,ION6OR1PUMP <br /> PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �/-�,7 <br /> � (Complete In Triplicate) <br /> construct <br /> Application is hereby made to the San Joaquin Local Health District for a permit to <br /> and/or install the work herein described. This application is made in compliance wi t <br /> County Ordinance No. 1862 anJoaquin Local Health <br /> the Rules and Regulations of the San th San Joaquin <br /> alth District. <br /> JOB ADDRESS/LOCATION714 <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> 3 City <br /> . ` Contractor's Name <br /> ' License # e 'YJ P tI oue p- <br /> TYPE OF WORK (Check).: NEW WELL /? DEEPEN _* <br /> /7 RECONDITION /? DESTRTICT'ION /7 ^_ <br /> PUMP INSTALLATION /� PUMP REPAIR /—/ <br /> Other /% MEPUMP REPLACEMENT <br /> :>DiSTANCE TO NEAREST; SEPTIC TANK <br /> . <br /> SEWAGE DISKS FIELDER LINES • PiT PRIVY <br /> CESSPQOL/SEEPAGE PIT <br /> INTENDED USE �. � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL OTHER <br /> PUBLIC DOMESTIC WELL' <br /> OF WELL <br /> Industrial Cable Tool CONSTRUCTION SPECIFICATIONS RJ <br /> - Dia. of, Well Excavation <br /> Domestic/private <br /> Domestic Drilled Dia. of Well Casing <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack: Depth of Grout Seal <br /> Cathodic Protection t �- Rotary <br /> Disposal • `� Other Type of Grout <br /> _. <br /> .Geophysical �_�,_.__` Other Information � <br /> Surface Seal Installed B I <br />'PUMP INSTALLATION: Contractor M <br /> Type of Damp ' <br /> H.P' <br /> PUMP REPLACEMENT. State Work Done <br /> PUMP :REPAIR: <br /> L7 State #; <br /> Work Done <br /> .-ES�TRUCTION OF WELL: ; _ � :Y.` . - •- - - - - " <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health <br /> and the State of California pertaining to or regulating well construction, District <br /> after completion of my work on a new well, I will furnish the San Joaquin Local hAealt FIFTEEN <br /> a :. <br /> WELL DRILLERS REPORT of the well and notify them before Putting-the-well in.use. <br /> information is true to the-best of my..know dge end belief. The above <br /> PRIOR TO G ING AND A FINAL INSP C'T ONS. I WILL GALT, FOR GRQUT INSPECTION <br /> SIGNED � � • Iii- <br /> ITLE 1 <br /> t RA PLOT PLAN ON ERSE SIDE <br /> �=� `.•/ FOR D <br /> PHASE INT USE ONLY <br /> ` � <br /> APPLICATION ACCEPTED By <br /> ADDITIONAL COMMENTS::'' C S DATE <br /> PHASE II GROUT INSPECTION <br />[NSPECTION BY DATEPHASE III FINAL INSPECTION <br /> INSPECTIONBX DATE - r <br /> E H 1426 <br /> Rev. 2-74 b <br />