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f ,{ <br /> - <br /> s ..SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> t P08 OFFICE..:lTSE: 1601,E. 'Hazelton Ave.`; Stockton, Calif. f <br /> Telephone:. .(209) 466-6781 <br /> N APPLICATION FOR WELL CONSTRUCTION OR:Pullp PERMIT Permit No-:.7d!(-&B,S~�. <br /> a TRIS PERMIT"EXPIRES' l <br /> YEAR PREM DATE'ISSUED Date Issued - 7 _.6 <br /> ` � (Complete lw,Triplica�te) -1 <br /> 3 Appiicatiot: heraby.:nada"to the, ap Jo4quia:Local Health District,for a permit-to:.construct <br /> `- <br /> and/or .instal3 the work herein daacr3bed. Thii-applicatioa-is made, fa compliance with"'.&M,7oagiiieti <br /> Caunty;Ordi�mt� 'No. '1862 atyd Lha Eulee aad.Ra latioai oft Sae Jaa Local Hea3tft District. ` <br /> JOB...7. S8/LOCATI '�'z!2 e .J CEN33IS.TB11GR ��` <br /> Whir <br /> k,v <br /> 'C3 _ <br /> s <br /> Contractor's Naas License <br /> i <br /> - <br /> TYPB OP MORE {Check)i4 NEW 1+BLL Dwpmu f RECONDITION %j DESTRUCTION <br /> �f PZDIP'INSTALLATIDN /? PUMP REPAIR /� Pini?' F: IlGEMBHT 'f <br /> other L? <br /> DISTANCE 7'O NlABEST. $"TIC;TANK SEWER LINES PIT PRIVY i <br /> $BwAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT .' OTR <br /> PROPERTY`'LINE -» PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC WELL ''b <br /> ED US$ TYPE OF WELL ." CONSTRUCTION SPECIFICATIONS. <br /> uatrial ` <br /> INTEND Ls <br /> Cable Tool Dia...of Well $xca��ation ,• f <br /> y _ Domestic/private 'Drilled Dia. of Well Casing .I <br /> rpoaieatic/public Driven. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout'SealA <br /> " Cathodic Pzatasction Rotary. : Type of. Grout; <br /> Disgasal Other' Other:Information <br /> y <br /> Surf ace Seal'-rust Iled $ <br /> PUMPNSTex e•rrON Coatraittor <br /> 0, 0 Pump S:P.. <br /> FUMP?REPLACEM f State WorGd <br /> r <br /> PUMP BEPAI$ /? State Work Done <br /> : <br /> D6 eTRUCTION`OIC iL We11:Di <br /> ameter _ Approxdmate. Depth <br /> DescriberMaterial and Procedure F a <br /> I.hereby agree to comply.,with:all laws and regulations of.the San Joaquin Locai:.Health District :, <br /> and the" State of California pertaining to or regulating wTell construction Within' PIFrHIId DAYS" <br /> of ter_completion of my. work on' a new.well, I trill:furnish .the Sae.Joa uin Local"Health'District a f <br /> WLLL 1RIrr_mrs PORT.-of the wrell.:and`notify them before 'putting .the .well in-use... <br /> The. above <br /> information,is true to the bestof- my..knowledge'.and :bel.ief. .I WILL CALL A GROUT INSPECTION= <br /> PRIOR TO CARO INCA.ANDA FINAL' IN'SPECTIO �v ti <br /> SIGNED: TI1 LE <br /> (DRAW PIAT PLAN ON REVERS?: SIDE <br /> r1 OR DEP TiiT USE ONLY <br /> PHASE' I`: <br /> l: <br /> APPLICATION ACCEP� BY 1 L soul DATE 3 , <br /> ADDITIONAL'COMMENTS <br /> PHASE II GROUT INSPECTION P INAL INSPECTION , <br /> I1iSP1;MOH BY 'DATE INSPECTION BY <br /> H H1426 Rev 1-74' <br /> 2M ``� <br /> _ r <br /> - 1 <br /> F <br />