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DIST <br /> ICT <br /> SAN JOAQUIN LOCAL HEALTH ton, Calif. ' <br /> 1601 E. Hazelton Ave. , Stockton, <br /> VOE:-OFFICE USE: " <br /> Telephone: (209) 466-6781 Permit No. 7 `SS I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT , <br /> _ Date Issued /�-// 71 <br /> THIS PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED <br /> (Complete In Triplicate) <br /> . 1 1struct <br /> A l.icatiou is hereby made to" the San Joaquin Local Health District for <br /> inrcomplianceit twith nSan Joaquin <br /> pP <br /> and/or install the work herein described. This application <br /> County Ordinance No. 1$62 and the Rules/ and Regulathe San Joaquin Local Health District. <br /> CENSUS TRACT 14 D <br /> JOB ADDRESS/LOCATION I - <br /> Phone Qa_ <br /> Owner's Name <br /> City , c <br /> Address t / <br /> License;1t32VL# Phone <br /> Contractor's Name x f <br /> s <br /> DEEPEN/_/ RECONDITION /_7 eDESTRUCTION /7 <br /> TYPE OF WORK (Check) : NEW WELL pip REPLACEMENT I�T <br /> PUMP INS�ATION PUMP REPAIR '/ I W <br /> other�/ I <br /> SEWER LINES / PIT PRIVY �.-- <br /> DISTANCE TO NEAREST: SEPTIC TANK lyr3 -F C S�SPpOLISEEPAGE PIT �. OTHER <br /> SEWAGEjDjsPOA FIELDdPROPERTY LIN PRIVATE DOMESTIC WELIr� -- PUBLIC DOMESTIC WELL <br /> TYPE OF WELL, CONSTRUCTION SPECIFICATIONS ` <br /> INTENDED USE <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled <br /> Dia. of Well Casing _ / " <br /> Driven Gauge of Casing <br /> iti <br /> Domestic/public t �. <br /> Irrigation 1 Gravel Pack Depth of GroutlSea1 <br /> Type o£ Grout .� <br /> Cathodic Protection I Rotary Other Information` <br /> Disposal Other <br /> ~Geophysical Surface. Seal _Insta.Iled.-B --d - <br /> PUMP INSTALLATION: ,;,,.Cont actor H.P. <br /> Type'� f 'Pump <br /> k PUMP REPLACEMENT: /r1' State Work Done <br /> PUMP .REPAIR: k' / /' State Work`Done <br /> ` -_�`° J Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> + Describe Material and Procedure . <br /> San 'oaquin <br /> c isrict <br /> I hereby agree 'to comply with all laws and <br /> reregulatingowellethe <br /> c6nstruction. Within F FTEENtDAYS <br /> and the State of California pertaining o <br /> ll furnish the San Joaquin LocalxHealth District a <br /> after completion of my work on a new well, I wi <br /> mbefore <br /> ove <br /> WELL DRILLERS REPORT of the well and notify .theandbelieftt�I WILL CALL FOR Aee <br /> GROUT INSPECTION <br /> information is true o he; of. my knowledge <br /> PRIOR TO TI G D FI INSPECTION. <br /> TITLE <br /> SIGNED <br /> � ., SE S <br /> pRp,W.:p�;'T PLAN ON- REVERIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> 4Z-7Z <br /> ? / <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ► PHASE FINAL INSPECTION <br /> PHASE II GROUT-INSPECTION INSPECTION BY DATE <br /> I INSPECTION BY DATE <br /> a ' <br /> CV 3/76 2M <br /> u 1A9A Rav- 1-74 — — — <br />