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_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephond%4',-( 9) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t the San JoaquT ��oaallHealth <br /> cation)istmade inrict rcompl compliance with San- a permit to uJoaquin <br /> and/or install the work herein described. PP , <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District' <br /> ler''` . CENSUS TRACT ! <br /> I JOB ADDRESS/LOCATION 1,1V.r r4 ✓ <br /> � �, ,'t' �- ,� �i ���%-� ��f�lti•`:��` Phone <br /> d = � <br /> Owner's Name �. rs <br /> ! <br /> .0.; y <br /> '� �,� � ,�'✓r��,`'i��� s�:cr19 S , - � y ,"��' ,. Cit 1<' <br /> Address " fly <br /> -� � =I: e°ense� � — �.� •Phone-a�.- �-����_ <br /> Con r-ac-tor`.s—Name <br /> t <br /> DESTRUCTION /rT <br /> TYPE OF WORK (.Check) : NEW WALL I DEEPEN / / RECONDITION �PUMP REPLACEMENT <br /> PUMP' INSTALLATION / /,'JPS °REPAIR ,// <br /> Other <br /> 6 <br /> DISTANCE TO NEAREST: SEPTIC TANK. �1w SEWER LINES�'�.� PIT PRIVY"�-< OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEFFAGE PIT, <br /> ` em'i'r- 'PUBLIC-DOMESTIC WELL " � <br /> -:PROPERTY-LIN --PRIVATE`-DOMESTIC"WELLCONSTRUCTION: SPECIIICATZONS <br /> ti kTYPE*OF WELL �_. -�7 _- -_ dw, <br /> INTENDED US'E . �,_ ... -'- "'' Dia. of We11 .Excavation <br /> Industrial Cable Tool <br /> Drilled Dia:. of .Well CAsing•. <br /> Domestic/privateDriven Gauge of Casing {' <br /> Domestic/public _ # Dep-th ..of abouts Seal <br /> ' Irrigation Gravel Pack <br /> Rotary Type of Grout '"` <br /> Cathodic Protection y Other Information +� r <br /> Disposal Other T <br /> Geophysical Surface Seal Installed{ <br /> . , � <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> x- Typ of Pump <br /> • t <br /> � PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / State Work Done <br /> f Approximate Depth . <br /> DESTRUCTION OF WELL: Well Diameter <br /> J' Describe Material and Procedure <br /> cal <br /> rict <br /> I hereby agree to comply with all laws and regulations of tleconstruction: o.WithinaFIFTEEN tDAYS <br /> y <br /> and the State of California pertaining to or regulating we <br /> after completion of my work on anew well, Ithemlbeforefurnish <br /> puttingatheonwell 'inouse..Health <br /> District <br /> above <br /> WELL DRILLERS REPORT of the well and notify <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR : GROUT INSPECTION <br /> i PRIOR TO GROUTING AND A FINA IN5 ECT ION. e.�e� � /�T�e�f� �t„ �,�^ <br /> , TITLE /''"' r <br /> t SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> CHASE? DATE J <br /> - s- ------� <br /> APPLICATION ACCEPTED BY I c <br /> ADDITIONAL COMMENTS: f PHASE III/FINAL INSPEC ,ION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY t DATE <br /> .4 . 0 7 7 - 2M <br />