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-- SAN JOAQUIN LOCAL HEALTH DISTRICT --Y <br /> FOSrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � s-r��o <br /> THIS PERMIT EXPIRES 1 YEAR FROM=DATE ISSUED Date Issued /D - s= <br /> (Complete In Triplicate) <br /> Application 1.8 hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This .application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 651 6 <br /> 717 <br /> Address <br /> City JT=AjEr-Lj <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /T DEEPEN I7 RECONDITION /-T DESTRUCTION /-j <br /> PUMP INSTALLATION / / PUMP REPAIR 17 PUMP REPLACEMENT 1 <br /> Other / J V�iv <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAI, FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �1 <br /> Domestic/public Driven. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal OtherOther Information <br /> —Geophysical Surface Seal Installed B . .. .r- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> �. 4 <br /> PUMP': <br />