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Z, <br /> —USE <br /> �. SAN JOAQUIN LOCAL HEALTH DISTRICTC2-) .nl6_" w Fc <br /> F,E—FF—1 s. <br /> OCE USE. �"` 1601 E. Hazelton Ave. , Stockton, Calif G,S1l� q. <br /> Telephone: (209) 1466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> X77-SS.SirJ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (COMPle <br /> In <br /> Application is Nereb de to the San Joaquin eLo alrHealthtDistrict for a permit to construct <br /> and/or install the work:lherein described. This application is made in compliance with. San Joaquin <br /> County Ordinance No.. 18' 2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> �i CENSUS TRACT <br /> t <br /> Owner's Name <br /> Phone . "5/ ^_ <br /> Address ' <br /> i� City .&C <br /> Contractor's Name <br /> License ��r�/ Phone <br /> I TYPE OF WORK (Check) : NEW WELL <br /> I. �/ DEEPEN './ / RECONDITION / / DESTRUCTION / 7 <br /> ECUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT /_7 <br /> oIther <br /> � <br /> DISTANCE Tp NEAREST: SEPTIC TANK + 77 <br /> SEWER LINES PIT PRIVY . <br /> + SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL�_l PUBLIC DOMESTIC.WELL <br /> INTENDED USE i TYPE OF WELL <br /> Industrial , _.CONSTRUCTION SPECIFICATIONS <br /> Cable Tool_ tpia:_!of -Well Excavation <br /> Domestic/private Drilledf� <br /> Dia. of Well Casing u <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation <br /> Gravel Pack_ . Depth,of. Grout 5ea-1:-4,. <br /> ' Cathodic Protecfion Rotary = Type of Grout <br /> DisposalOth <br /> er � Other Information <br /> �Geophysical Surface Seal Installed. B : <br /> PUh4P INSTALLATION: Contractor ` <br /> Type of Pump H:P: <br /> PLOP REPLACEMENT: �'- -;A <br /> J�/ S tate Work Done ' <br />---- "Work"Done , <br /> -,• =-+.-a-- -� --;�.� <br /> rtF,, • � <br /> DES•�RtTCTION OF WELL: We'll Diameter A <br /> iF pproximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sap. ,Ioaquin Local Health District <br /> and he State of California pertaining to or regulating well 'con S.tr"uction. Within FIFTEEN DAYS F <br /> oft�±r' completion of my wo'.rk on a new well, I will furnish the Sari'f- Toa4uin Local Health District a <br /> WELL DRILLERS REPORT of the well and notifythem before <br /> putting the%,Well in use. The above <br /> information is true to the bes o knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIQR'" TO GP TING D A F�F A N ION. <br /> SIGNED <br /> TITLE <br /> IM (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II'-GROUT-INSPECTION �..� kqr PHASE III/FINE— <br /> INSPECTION BY __DATE .- - _ .-INSPECTION BY ( ya .�fir� __.DATE <br /> F <br /> E H ,1426 Rev.. 1-74 �_ - 71/2.7"': � `' <br />