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SAN iTQQUIN FOCAL HEALTH DISTRICT <br /> ]E OFKTCE USE: 1601 E. izelton Ave. , Stockton, Calif.0 <br /> Telephone:p (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 3lication is hereby made to the San Joaquin Local Health Distric rro <br /> p�t o�onstruct <br /> i/or install the work herein described. This application is ma inTinee ith San Joaquin <br /> inty 'Ordinance No. 1862 and the Rules and Regulations of the San q�Ioca1 alth District. <br /> 3 ADDRESS/LOCATION _ ,' G s� CENSUS TRACT <br /> ter s Name ,_C� s. � ,;�;-= �=•� Phone <br /> Tress <br /> Cit <br /> y <br /> itractor's Name , License # Phone- <br /> ?E /-7 . <br /> • <br /> OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 . <br /> PUMP INSTALLATION / J PUMP REPAIR J / PUMP REPLACEMENT <br /> Other <br /> r <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia, of Well Excavation 4� <br /> Domestic/private Drilled Dia, of Well Casing <br /> c <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �r <br /> Cathodic Protection Rotary Type of Grout <br /> T Disposal Other Other Information <br /> Geophysical Surface Seal Installed By;,., f <br /> .IP INSTALLATION: Contractor . <br /> - - -- - <br /> Type of Pump H.P.-­­ <br /> _77 <br /> .P.-..�._ ) . <br /> !4P REPLACEMENT: / % State Work Done <br /> .REPAIR / f State Work Done <br /> TRUCTION OF WELL: WelL Diameter Approximate7Depth <br /> Describe *terial and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local� Health District <br /> d the State ,of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> ter completion of my work on a new well, I will furnish the San Joaquin Local; Health District a <br /> LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the best of my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> COR TO GROUTING AND FINAL INSPECTION. <br /> GNED �c- _ ^�J �%�' - - TITLE `��t%t�r� % <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ASE I <br /> 'PLICATION ACCEPTED BY DATE' �_7/7 <br /> i <br /> jDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION' PHA§E I INAL NSPECTION <br /> fSPECTION BY DATE INSPECTION BY DATE 7 <br /> i <br /> 3/77 . _ . 2M <br />