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Cp yi 16 401( I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH.: FF:IC•E USE 1601 E. Hazelton Ave. , Stockton, Calif. s <br /> - b Telephone: (209) 466-67$1 Permit No. � € <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERI'ff'T <br /> Date issues <br /> THISPERMITEXPIRES. 'l YEAR, FROM DATE ISSUED � -� y <br /> (Complete In Triplicate,) ruct <br /> Application is hereby made to the San Joaquin Local Health Distract inct rcompliance to const Joaquin- <br /> and/or install the work- herein described.. This -application <br /> County Ordinance No. 1$62 and the Rules and Regulations of the .San Joaquin Local Health Distract, <br /> ,� CENSUS% 'TRACT <br /> J' ADDRESS/LOCAT 011' �r.��.�a� Sa$Ia . <br /> Owner's Name <br /> City <br /> {t +r41 '�"!J Phone <br /> Address -A� g <br /> ��. a LicensePhone -`�� <br /> Contractor's Name <br /> DESTRUCTION /? <br /> TYPE OF 'WORK (Check) : ;NEW WELL f / DEEPEN ./ / RECONDITION / / i <br /> :,PUMP INSTALLATION / / PUMP REPAIR ICI i' REPLACEMENT <br /> .,Other. / / f <br /> DISTANCE TO NEAREST: SIEPTIC TANK SEWER LINES PIT PRIVY C/ <br /> SEWAGE DISPOSAL .F.IELD CE5SP0{3L/SEEPAGE' PIT OTHER <br /> 1 PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECTFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia, of We-1-1-Casing <br /> Domestic/private; <br /> Domestic/p <br /> ublic Driven Gauge' of Casing <br /> � Irrigation i Gravel Pack v Depth -of Grout Seal. . <br /> #" T e of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> Geophysical ? Surface Seal Installed By: <br /> ► PUMP INSTALLATION: % - Contractor �v4t,0000V <br /> H.P. <br /> Type of Pump �✓ ° <br /> PUMP REPLACEMENT: I l ' State Work Done. <br /> PUMPREPAIRStave Work Donet <br /> ` L Approximate Depth <br /> DESTRUCTION OF W,,ELL: Well Diameter <br /> Describe Material and Procedure <br /> i <br /> I hereby agree tocomply with all laws and regulations of the San Joaquin Local Health District <br /> and the State ot6 'com.fornia pertaining to or regulating well Within FIFTEEN DAYS <br /> construction. <br /> after completion of'lmy 'work on a new well, 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 m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING ANDIA FINAL N E f <br /> TITLE - - <br /> SIGNED 11 11W PLOT PLAN OqtZ-� ;t VERSE SIDE) <br /> F DEPARTMENT USE ONLY -? <br /> PHASE T 'j _-_ DATE �y <br /> .APPLICATION ACCEPTEDIBY ' <br /> ADDITIONAL COMMENTS: 'I: P' <br /> PHASE 1T GROUT INSPECTION PHASE 11IfFINAL INSPECTION <br /> INSPECTION BY I� <br /> DATE INSPECTION BY, DATE ",� <br /> 2M <br /> F H 1426 Rev. , 1-74 <br />