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F0670 MCE USE., SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ;. Telephone: <br /> -(209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> No. � 7r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEI5SUED <br /> In Tri Date Issued js <br />� Applicntion is hereby made <br /> and/or install the work her to the Sart (oaquineLocal Health <br /> te} <br /> ein described. District for a permit to construct <br /> lBs2 hisap <br /> This application is trade in compliance with San Joaquin <br /> County Ordinance No. and the Rules and <br /> ' Regulations of the Sa tt Joaquin Local Health District. <br /> JOB ADDRESS/LOCAxION <br /> CENSUS TRACT <br /> Owner's Name „ 14 <br /> Address Phone ' <br /> Contractor's Na - City <br /> License # f Phone Z — ` d <br /> -TYPE OF WORK (Check}: NEW WELL / DEEPEN ' <br /> PUMP INSTALLATION`/ // p' -' REAIPD <br /> TION / ESTRUCTION %j <br /> Other / / REPLACEMENT /"7 <br /> DISTANCE TO NEAREST: -- <br /> SEPTIC TANK SEWER LINES _ <br /> SEWAGE DISPOSAL FIELD PIT PRIVY ` <br /> PROPERTY LINE - PRIVATE mMEST�CSWELI, SEEPAGE PIT OTHER <br /> INTENDED. USE TYPE OF WELL PUBLIC DOMESTIC WELL <br /> _ Industrial �� Cable Tool CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Dia. of Well Excavation <br /> Domestic —...�. Drilled Dia. of Well Casing . <br /> /public �� Driven � <br /> Irrigation Gravel Pack Gauge of Casing <br /> # al ( , <br /> Cathodic Protection �� Rotary " <br />_„Disposal Y Depth of Grout Se <br /> Type of-Grout <br />.Geophysical E Other Other Information <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION. \ <br /> Contractor <br /> Type .of Pump " <br /> _ . ) H.P, <br />.'UMP REPLACEMENT: - <br /> // State Work- Done # <br />'UMP ".REPAIR: <br /> /�C/ State Work Done <br /> E&TRUCTION'OF WELL:. Well, Diameter <br /> Describe;Material and Procedure Approximate Depth <br /> hereb - � <br /> y�.�Agree to comply with all laws and regulations of the <br /> San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. <br /> fter completion of my work oil a new well, I will furnish the San Joaquin Local hHealth DEN DAYS <br /> ELL DRILLERS REPORT of the well and notify them before putting. the..well. in.use.... The District a <br />''formation is..true to- the best .of m above <br /> JOR TO, OU ING 'AND Y e ffd`�be ief. I WILL s <br /> FINAL INSPE ON. CALL "FORA "GROUT INSPECTION <br /> CGNED. - <br /> ' � LE <br /> D P 0 P ON SE SIDE <br />[ASE I �' R DEPARTMENT USE ONLY. <br /> FL TION ACCEPTED B <br /> DITIONAL COMMENTS: DATE ,0 l <br /> PHASE II GROUT INSPECTION <br /> SPECTION BY DATE; P?dASE III FINAL INSPECTION <br /> INSPECTION BY DATE <br /> E H 1426 <br /> Rev..-1--74 <br />