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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH� OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> • <br /> Telephone : <br /> (209) 466-6781 77 47 <br /> APPLICATION( II APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N <br /> /! . s THIS'PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> `.� Com Date Issued �d J <br /> Application is hereby made to the San Joaquin Local rHealthtDistrict fora e 41) <br /> s4- c y'�� <br /> and/or install the work herein described. This application is made in compliance with San Joaquii <br /> permit to construct <br /> County Ordnance No. 1862les and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS 11/LOCATI pry• <br /> CENSUS TRACT R [� <br /> Owner's Name N. <br /> 11 Phone <br /> Address <br /> y/d� <br /> Address I <br /> s IT. <br /> Contractor Is Name <br /> 1 s city <br /> Q YLicense #&& Phone <br /> t7 <br /> TYPE OF WORK_ (Check).: NEW W.ELI;..J "—�DEEpEN,�Z;I REC{)NDITIONh--/-/�-DESTRUCTION-' �-— <br /> .PUMP INSTALLATION /? <br /> I1 / PUMP REPAIR / / PUMP REPLACEMENT : <br /> � <br /> ' Other / / <br /> DISTANCE TO NEAREST: SEPTIC <br /> " O SEWER LINES / PIT PRIVY <br /> 4 SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> `p <br /> PROPERTY OTHER <br /> LINE= PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ;TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> k Cable Tool Dia, of Well Excavation /f 2 �j <br /> .r Domestic/private �. _ Drilled -, <br /> Domestic/public - Dia. of Well Casing <br /> ai ,.= Driven Gauge of Casing <br /> Irrig ion Gravel Pack / <br /> Cathodic Protection � � RDepth of Grout Seal <br /> otary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophy s'i c a.1 --------- <br /> Surface Seal .Installed By: <br /> PUMP-INSTALLATION: Contractor <br /> Type of Pump <br /> I H.P. <br /> _ <br /> PUMP REPLACEMENT: I �" <br /> / / State Work Done. <br /> PUMP :REPAIR: / / State Work Done " <br /> �I <br /> DE-S-TRUCTION-OF WELL: `"Well Daiametex <br /> Approximate Depth <br /> Describe Material and ProcedureP <br /> YAW <br /> I hereby agree to cwith all laws and <br /> and the Stateof Californiaiforegulations of the San Joaquin Local Health District <br /> pertaining to or regulating we <br /> completion of my work~onlll construction. Within FIFTEEN DAYS <br /> after a new well, I will furnish the San <br /> WELL DRILLERS�REPORT of the well and notify them before putting-_theowellninocal use..HeThe haboveric 'a <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />.3 OR TO GROUPING AND A ZINAL INSP ON, <br /> SIGNED - # <br /> TITLE <br /> (DRAW PLOT PLAN ON` REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: '` " 4 DATE <br /> PHASE II GROUT INSPECTION INSPECTION <br /> INSPECTION BYMI. DPHAS I/FI <br /> TETE INSPECTION DATE <br /> E H 1426Rev. <br /> 1-74 ,_... <br />