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��� � 51 .. 'LY,i • ie � >,�., n " ! l r fA���. Y a .. .�. ! n��ry Y} <br /> h • <br /> .+r+.. .,ur�ttuJn 1-Ut AL =-ALLN UlbIKILl 1i ' <br /> FOE OFFICE USE 16G1 E. Hazelton Ave , Stockton, Calif. <br /> _ r C• <br /> +, 4 ",��, �✓ Telephone (209) 466-6781 �h <br /> APPLICATION FOR WELL CONSTRUCTIO �1 O Permit No. �0 f <br /> THIS PERMIT EXPIRES I YEAR FR E ISSUED Date Issued h1 <br /> J (Complete In Tripl at lain' Appljca�tion is hereby made to the San Joaquin Local He 11th orstricn`E Va a permit to construct <br /> s;lt- and/or-install the work herein described. This applies fAfipFApt}liance with San Joaquin <br /> a "Couaty Ordinance No. 1862 and the Rules and Regulations °�F J q#n Local Health District. <br /> 'JOBS ADDRESS/LOCATIONy CENSUS TRACT <br /> c Owner's Name — - . Phone % - <br /> sK Rp <br /> Address City <br /> f• Contractor's NameLicense #Phone <br /> TYPE OF WORK (Check)• NEW WELL DEEPEN / RECONDITION !_7 DESTRUCTION <br /> PUMP INSTALLATION _ _ PUMP REPAIR 1-7 PiJ?D? REPLACEMENT f7 <br /> Other <br /> ' DISTANCE TO NEAREST SEPTIC TANK IA dI SEWER LINES PIT PRIVY <br /> SEWAGE DISP SD AL FIELD �2tl CESSPOOL/SEEPAGE PI—T7;g;, C.AER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL 9XZ PUBLIC DOMESTIC WELL <br /> yrs , INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFILATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled <br /> Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation k Gravel Pack Depth of Grout Seal r <br /> i Cathodic Protection �� Rotary Type of Grout <br /> Disposal' Other Other In€ormation <br /> Geophysical Surface Seal Installed BY. , <br /> T PUMP INSTALLATION: Contractor <br /> i ' Type of Pump H.P. <br /> }x K i PUS REPLACEMENT* / / State Work Done <br /> r _ <br /> PUMP REPAIR: / / State Work Dore <br /> DESTRUCTION OF WELL Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> rafter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <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 C.,?,L FOR A GROUT INSPECTION <br /> PRIOR TO G UT NG FI AL INSPECTION <br /> SIGNED TITI E � <br /> (DRJ.W PLOT PLAN ON REVERSE SIDE <br /> � FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ;APPLICATION ACCEPTED BY �` r� �0. DATE <br /> ADDITIONAL COMMENTS ^- <br /> P SE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - INSPtCTION BY 0&aDfiTE <br /> 1/77 _ 2H <br /> E H 1426 Rev 1-74 <br />