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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, <br /> FOR Calif <br /> OFFICE USE: . <br /> Telephone: (20g) �466-6781 permit No. �� <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 7l 7 g� ra1 <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date .Issued � , <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made tolthe San Joaquin Local <br /> lxHcalt D ismadeinrict rcompliance with San Joaquin <br /> and/or install the work herein described. This app h <br /> Count Ordinance No. 1862 andrthe Rules and Regulations of the San Joaquin Local Health District. ' <br /> y <br /> � CENSUS TRACT <br /> JOB ADDRESS/jo@AjF4-QN p <br /> Phone � <br />" aner's Name + <br /> City <br /> Address � �7��� /License � �`Phone �' a <br /> I; Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL DEEPE I I RECONDITION I_7 DESTRUCTION /� <br /> • PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> ` <br /> Other : / / "* 4- <br /> SERT PRIVY <br /> DISTANCE TO NEAREST: SEPTICjTANK IELDME'�� NECESSPOO/SEEPAGE PI�rf-OTHER <br /> SEWAGE DISPOS <br /> b.PROPERTY LIN PRIVATE DOMESTIC WELL CUNbRUCTION SpPUBLIC MEIFICATIO S <br /> INTENDED USE TYPE OF WELL <br /> Industrial t Cable Tool Dia. of We <br /> 11 Excavation / <br /> -�«--� Drilled Dia. of Well Casing <br /> Domestic/private Driven '" Gauge of Casing <br /> � <br /> Domestic/pub lic � Gravel Pack Depth of Grout Seal, <br /> Irrigation rotection Rotary Type of Grout <br /> Cathodic POther Other Information <br /> Disposal <br /> � w Surface Seal .Installed BY: <br /> Geophysical 01 <br /> TTT r <br /> i <br /> PUMP INSTALLATION: Contractor sa ` ' H.P. <br /> Typel of Pump <br /> PUMP REPLACEMENT: /` State Work Done <br /> PUMP .REPAIR: / / State. Work Done <br /> • r Approximate Depth <br /> + DESTRUCTION OF WE We11". Diameter. <br /> Describe Material and Procedure <br /> o cam 1 with all laws and regulations of the ,San Joaquin Local Health District <br /> y I hereby agree t P y <br /> I and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I willlfurnish ut e Sa JoaqthellU'ininouse.HeThehaboverict <br /> WELL DRILLERS REPORT of the well and notify the before <br /> i <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT OilS <br /> SIGNED <br /> „ D W PLAN 'ON RE ERSE SIDE) <br /> FOR DEPARTMENT ONLY <br /> PHASE I DATE 747:::� Z 7 — <br /> APPLICATION ACCEPTED BY� <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 7 2 ti' s <br /> INSPECTION BY 1 DATE <br /> 3/76 2M- <br /> E H 1426 fRev-t'l-74 - <br />