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�• .� k; - � SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> F0 AFF USE: Stockton Calif. <br /> 1601 E. Hazelt.on Ave, , � <br /> Telephone: (209) 466-6781 <br /> pI;ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> d -6-� <br /> Date Issue ; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �—--Z <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquinsoaalealthlication District <br /> tmade incompliance <br /> for <br /> to construci <br /> with San Joaquin. <br /> and/or install the work herein described. This pp <br />' County Ordinance No. 1862 and the,,Rules and Regulations of the San Joaquin Local Health Distri:�t. <br /> CENSUS TRACT ' <br /> i JOB ADDRESS/LOCATION <br /> Phone <br /> r Owner's Name <br /> ,,_,l City ✓ <br /> Address �� v <br /> License # �3Phone ,L <br /> Contractor's Name <br /> .i <br /> NEW WELL / DEEPEN RECONDITION / DESTRUCTION /7 <br /> TYPE OF WORK (Check) : <br /> PUMP INSTALLATION El PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> n Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY CESSPOOL/SEEPAGE PIT OTHER l� <br /> SEWAGE DISPOSAL FIELD <br /> STIC WELL <br /> PROPERTY DINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPPUBLIC ECIFICATIONS v <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation �� C <br /> _ Drilled Dia. of Well Casing _ <br /> Domestic/private Driven Gauge of Casing � 1---- <br /> Domestic/public Depth of Grout Seal <br /> Irrigation Gravel Pack p <br /> -y—�--� Rotar Type of Grout -� <br /> Cathodic Protection y Other Information <br /> Disposal Other <br /> _ Surface Seal Install <br /> Geophysical <br /> n <br /> PUMP,. INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / Stat` Work Done <br /> PUMP .REPAIR:,, State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF.WELL: Well Diameter <br /> Describe Material and Procedure <br /> i, <br /> I hereby agree to comply with all law <br /> and o�egegulatingowell'construction.f the Sa i Joaquin LoHealth t <br /> WithinFIFTEENDAYS <br /> and the State of California pertainingJoaquin <br /> after completion of my work on a new wI will <br /> hm bfurnish <br /> efore putthe <br /> San <br /> -well ineuse.HeThe habove <br /> r�ct <br /> WELL DRILLERS REPORT of the well and notify <br /> is true to the best of my. know dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> information <br /> PRIOR TO GROU ING AND A FINAL PECTION. r � TITLE <br /> SIGNED D W PL T pL ON REVERSE SIDE) ' <br /> FOR DEP MENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY __LW_j2_ <br /> ADDITIONAL COMMENTS: PHASE III/F NAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE 7i- <br /> INSPECTION BY DATE <br /> 3/76 2M <br /> k F 14 1426 Rev. 1-74 , <br />