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FOR.iOFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. Hazelton Ave.', Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7�s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete In Triplicate) Date Issued 7- 75, <br /> Application is hereby made to the San Joaquin Local Health 1�istrict 0' a 2-30 it to <br /> and/or install the work herein described. This .apl Health is made for <br /> compliance construct <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Loc <br /> mP with San 3oaquia <br /> '26,353 .) . 6'p;gkA,,,.( R al Health District. <br /> .SOS ADDRESS/LOCATION <br /> - ~ `"""`�'-P CENSUS TRACT <br /> Owner's Name -�1� <br /> /ti <br /> Address Phone <br /> (Q � 3 p_#� . <br />' City . <br /> Contractor's Name <br /> License #��2 Phone <br /> TYPE OF WORK (Check); NEW WELL/ <br /> _� DEEPEN '/-7' RECONDITION /7 DESTRUCTION � <br /> PUMP INSTALLATION /� PUMP REPAIR PUMP REPLACEMENT %f <br /> Other i I <br /> t 1�/ `Fr �� <br /> DISTANCE TO NEAREST: SEP TICTANK <br /> • SEWAGE �DISPOSAL FIS R LINES PIT PRIVY <br /> PROPERTY LINE - PRIVATE DOMESTICCkSSPOOWEL' L '— <br /> (I. /SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> PUBLIC DOMESTIC WELL <br /> _, Industrialz +r CONSTRUCTION SPECIFICATIONS W " <br /> Domestic —, Cab1e Tool Dia. of We" Excavation <br /> /private_._. --._ ._ Drilled <br /> . �._, Domestic/public ,ti. �. �' -Dia:of Wel -Casing <br /> Irrigation "i <br /> Driven. Gauge of Casing <br /> Cathodic Protection ;'- Gravel Pack Depth of Grout! Seal <br /> -.Disposal _ Rotary e y <br /> � d..:�."�T ^ �, �..:. � � - Other Type of Grout, <br /> oPhy$ical�- —= _--�- Other information,� . ._ <br /> SurfaceSealInstalled B <br /> PUMP INSTALLATION: Contractor' <br /> Type 'of Pump ' <br /> H.P. /D <br /> PUMP REP LACEMENT: 1 <br /> tState Work Done <br /> PUNl3�:REPAIR:•, ,, 5tate_Work-D9ne.. ./: ,T h <br /> RS RUCTION OF WELL: <br /> Well Diameter -^ <br /> DescrApproximate Depth <br /> nd Procedure <br /> I hereby agree- to comply with all laws and regulations of the San Joa uin Lo <br /> and the State of Caiifornfa pertaining to or regulating weil 'construction. <br /> 4 cal Health District <br /> after completion of My work 'on a new well, I will furnish the San Joaquin Loc <br /> WELL DRILLERS REPORT of the well and notify them before Within Health <br /> District <br /> DAYS <br /> information is true to the-best-of m q se AeThth District a <br /> putting. the. well in-use.. The above <br /> PRIOR TO GROU NG ANDA y knowledge and belief. I WILL. <br /> SIGNED <br /> NAL INSPECTION. CALL FOR 'A 'GROUT INSPECTION <br /> J TITLE <br /> DRAW PLOT PLAN ON ItEVERSk SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> PLICATIONACCEPTED 'BY <br /> ADDITIONAL COMMENTS: DATE . ' <br /> PHASE II GROUT INSPECTION ` <br /> INSPECTION BY PHAS <br /> DATE III FINAL INSPECTIO <br /> INSPE Ti0 Y <br /> DATE <br /> E'H,1426 <br /> .Rev. 1-74 <br />