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Alic <br /> ' k SANJOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1661 E. Hazelton-'.Ave. , Stockton <br /> , Calif. <br /> Telephone;: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N°' 72-_5­3 j � <br /> Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Heal�onDrict istra permit t <br /> PP <br /> made incompliancewithnSanuJoaqun <br /> and/or install the wank herein described. This applicat <br /> lations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regu <br /> CENSUS TRACT <br /> E JOB ADDRESS/LOCATION <br /> f _ Phone <br /> Owner's Name — �J <br /> City <br /> Address <br /> �`j ..y ,t ,. �T. ' 5Phonel 2,1 <br /> s <br /> 4 Contractor's Name <br /> z; _.. <br /> �� . N RECONDITION /� DESTRUCTION /�' <br /> TYPE OF WORK (Che'ck): NEW WELL / DEEPEN / REPAIR I I PUMP REPLACEMENT 17 <br /> PUMP INSTALLATION -/`�P <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Q'B SEWER LINES PIT PRIVY OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �MESTIC WELL <br /> PROPERTY -LINE - PRIVATE DOMEL DOMESTIC WELL PUBLIC,bO •. �- <br /> C INTENDED USE 'TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> ' Cable"final Dia. of Well Excavation <br /> Industrial t Dia. of Well Casing r Ly <br /> Drilled'" ` <br /> j/Domestic/private ; 4 ' Driven ''a* I Gauge of-CA-9i x g <br /> q <br /> Domestic/public k. <br /> Irrigation Gravel Pack Depth of Grout Seal k <br /> _T ew o. Grout —�----6� <br /> Cathodic Protection Rotary Other Information <br /> -Disposal Other a <br /> <` Surfice'§e-al Installed B <br /> Geophysical, <br /> PUMP INSTALLATION: Contractor > H:P. <br /> Type of Pump,- , XJ <br /> PUMP REPLACEMENT: 1 I State Work Done. • { <br /> - FLIMP-rREPAIR:�- h/ State Work .Done - <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> _ <br /> Describe Material and Procedure <br /> in ti <br /> al <br /> I hereby agree to comply with all laws and regulalatn's of theconstruction.LoWia <br /> thinFIFTEENlthtrictDAYS , <br /> and the State of California pertaining to or reg g <br /> after 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 tife_m 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 GROUT D �FNIION• TITLE <br /> SIGNED <br /> iY �itAW P T PLAN �ON RE R SID <br /> E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> r APPLICATION•,,ACCEPTED BY .� <br /> t ADDITIONAL COMMENTS: �.� PHASE III/FINAL INSPECTION <br /> t PHASE II .GROLTT INSPECTION DATE _ <br /> INSPECTION BY DATE DATE t3 + IS INSPECTION BY <br />