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(/ SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> � � .. r <br /> FOR OFFICE USE* 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone: (209).,\466-6781 Permit No. �3 4J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER <br /> Date Issued � 77 <br /> (Complete In Triplicate) permit to construct 4 <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> and/or install the work herein described. This <br /> application <br /> the SaneJoaqin uin LocaleHealth SDistrict�n I <br /> County ordinance No. I$62 and the Rules and Regulations i <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION �6� -Z <br /> Phone <br /> Owner's Name J. t <br /> city � << <br /> Address6 <br /> ~� License <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION / / DESTRUCTION./~T , <br /> PUMP INSTALLATIONS / / PUMP REPAIR / / PUMP REPLACEMENT / T s <br /> Other / <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ;.PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> E INTENDED USE TYPE 0 WELL CONSTRUCTION SPECIFIGATIONS <br /> 4. industrial Cable Taol Dia. of We11 Excavation � � <br /> te <br /> Drilled Dia. of Well Casing <br /> ---�pomestic/privaDriven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel 'Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other . Other Information <br /> Disposal Surface Seal Installed B <br /> .Geophysical - <br /> PUMP INSTALLATION: Contractor H.P. <br /> +, Type of Pump <br /> -PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: . / / State Work Done a. <br /> rDES•TRUCTION OF WELL: Well Diameter a <br /> IP'4 ^Approximate Depth . <br /> Describe Material and Procedure <br /> lth <br /> rict <br /> San Joaqui <br /> 4I hereby agree to comply with all law s andto oregelulatingTons owell construction.`LoW thinaFIFTEENtDAYS <br /> and the State of 'California pertaining <br /> after completion of my work on a new well, Ithemlbeforesputtingathe ellninouse..HeThe habove <br /> rict a <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�.A GROUT INSPECTION <br /> PRIOR TO GRO ING A FINAL INSPECTION. ` F y E <br /> TITLE <br /> SIGNEDi <br /> ! (DRAW. PLOT PLAN ON •REVERSE S-1-DE) � - t� • <br /> FOR DErARTMENT USE. ONLY <br /> t <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY ._� <br /> ADDITIONAL COMMENTS: f PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION fINSP•ECT.ION_ Y -.� - DATE__ G _ <br /> INSPECTION BY DATE - 4 <br />