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SAN JOAQUIN LOCAL HEALTHStockton, <br /> F"OF� OFFICE USE. 1641 E. Hazelton Ave. , <br /> �.., Telephone: (209), 466-6781 RPermit No. 2/° <br /> APPLICATION FOR WELL CONSTRITCTIOI� OR PUMP PERMIT <br /> Date Issued 2Z-j_-2_,d- <br /> THIS <br /> Z,,;,�;�G <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED I <br /> /" (Complete . Triplicate) <br /> he San Joaquin Local Health District for twithnSan .loaquin�; <br /> Application is hereby made to lication is made in compliance <br /> and/or in the w�k herein described. This app <br /> I <br /> County Ordinance No: 1862 and-the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT -------_ A. <br /> JOB ADDRESS(LOCATION q-3 j ass <br /> a <br /> Phone <br /> E. Owners Name ' <br /> City ' <br /> I I' ' <br /> Address `�' <br /> License #/�� Phone <br /> Contractor's Name ' <br /> _ RECONDITIONS' DESTRUCTION _ <br /> TYPE Off' WORK (Check) -. NEW WELL /� TI NPS/,� REPAIR I' I r� REPLACEMENT /? <br /> PUMP' INSTALLA <br /> i Other <br /> fSEWER LINES PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK _ CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE -- PRIVA E DOMESTIC MELZ CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE (TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domeatic/public <br /> �' Driven Gauge of Casing <br /> I Irrigation � t Gravel Pack Depth of Grout Seal <br /> I Cathodic Protection ' _ Rotary Type .of Grout <br /> Information <br /> Disposal Other . Qther <br /> Geophysical <br /> Surface Seal Installed B <br /> _ � ._ � <br /> PUMP INSTALLATION. Contractor H.P. <br /> I <br /> Type of Pump ` <br /> i PUMP REPLACEMENT: / / State Work Done <br /> t PUMP 'REPAIR:,— �� '" f7—State Work Done <br /> �DES4RUCTION OF WELL:. Well, Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> land the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> lafter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well. in.use... The above <br /> information is true to the''best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED a. 'TITLE <br /> :i (DRAW PLAT PLAN ON REVERSE SIDE <br /> j F DEPARTMENT USE ONLY <br /> PHASE 'I <br /> iAPPLICATION ACCEPTED BY DATE ' f <br /> H'ADDITIONAL COMMENTS--,, <br /> PHASE,II OROPTL_ PHASE III FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE �. <br /> P 2M <br /> r R H 1426 Rpvr 1-74 <br />