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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE• 1601 E. Hazelton Ave. , <br /> Stockton, Calif . <br /> Telephone: (209) 466-6781 <br /> A7THIS: PERMIT <br /> CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. 7yp <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued -72 <br /> (Complete In Triplicate) permit <br /> Application is hereby made tol.the San Joaquin LacalHealthlication istrict made inrco pliancetwith SanuJoagin <br /> PP <br /> and/or install the work herein described. This app <br /> Count Ordinance No. 1862, an6ithe Rules d Regulations of the San Joaquin Local Health District. <br /> y Q G CENSUS TRACT <br /> JOB ADDRESS/LOCATION 3 �l - <br /> ,�- Phone _ <br /> Owner's Name <br /> City <br /> Address <br /> License �SoYa hone <br /> Contractor' s Name 711 t <br /> RECONDITION_/ DESTRUCTION �� <br /> TYPE OF WORK (Check) : NEW WELL /�/�DEEPEN I / REPAIR / / . PUMP REPLACEMENT /_7 <br /> PUMP INSTALLATION ISP <br /> Other / / <br /> -SEWER L NES T PRIVY <br /> DISTANCE TO NEAREST: SEPTIC] TANK d CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DIS SAL FIELD ? --- PUBLIC DOMESTIC .WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> = % Cable Too �." Dia. of Well Excavation !/1 <br /> _1zIndustrial Dia, of Well' Casing <br /> omestic/private I Drilled •� <br /> Driven .. Gauge of Casing <br /> f Domestic/public G <br /> Irrigation ravel Pack► Depth of Grout Sea] d <br /> - <br /> Type of Grout <br /> ( �tary <br /> Cathodic Protection Other Other Information <br /> s Disposal <br /> Surface Seal Installed B <br /> -,Geophysical f <br /> ' PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / Ti State Work Done <br /> State Work-Done <br /> PUMP RE �'_ / <br /> � / : <br /> Approximate Depth <br /> OF OF WELL: Well Diameter <br /> k Describe Material and Procedure x <br /> r <br /> k <br /> I hereby agree to comply witrict <br /> h all laws and regegulatin °welleco struction.LOWithincal aFIFTEE13lth tDAY5 <br /> and the State of California pertaining to or re$ �.$� <br /> after completion of my <br /> work on a new well, I will furnish the San Joaquin Local Health District <br /> above <br /> WELL RILLERS REPORT of tlye well and notQwledhemandfbeliefore putting ILL CALL FOR Athe well in eGROUT eINSPECTION <br /> inform 'on is true to the best P my- n 8 F <br /> PRIOR TO UTING ANDA TITLE (2-d=— ° oL ' <br /> SIGNED SE SIDE) <br /> _ FOR DEPARTMENT USE ONLY' <br /> PHASE F Y_III APPLICATION ACCEPTED B1-9-4 <br /> , <br /> ADDITIONAL COMMENTS: .� PHASE I / INAL' INSPECTION <br /> PHA GR T INSPECTION Y <br /> TE 7 7 <br /> DATE INSPECTION B <br /> INSPECTION BY 376 2M <br /> n u IA9A Rav_ 1-74 <br />