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- yt�ol <br /> � SAN 30AQUIN LOCAL HEALTH DISTRICT <br /> 'Stockton, Calif . <br /> 'OFFIct USE: 1601 E. Hazelton Ave. , rz <br /> 20g 466--6781 Permit No. ' � <br /> Telephone: ) <br /> APPLICATION FOR WELL CONSTRU% CTION OR PUMP PERMIT Date Issued <br /> TlitS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) ermit to construct <br /> This application is made in ,compllaa eHealth.District. <br /> with San Joaquin <br /> Appli <br /> cation is hereby made tthe San Todaquh .Locpl Health District fox amp Loc <br /> and/or install, the work :hexein •describe Mations of the San Joaquin <br /> Ordinance No. 1862 and. the Rules and Reg CENSUS TRACT <br /> I - <br /> JOB ADDRESS/LOCATION - Phone .36?g-4-�7� <br /> ' 1 �t�� .J Enr�� <br /> Owner s Name T / ---� <br /> city <br /> Address O �s O S� �+V-Phone a � 77 <br /> ` y21-L�-i hCC License �t���---- <br /> Contractor's Name � <br /> SD� .. <br /> _ 1' DESTRUCTION /_7 <br /> DEEPEN I RFCONDiAON_�I <br /> TYPE OF WORK (Check) NEW WELL / I r� REPAIR / / PUMP REPLACEMENT I I <br /> INSTALLATION / <br /> Other ./ I <br /> !1 SEWER LINES i PIT PRIVY OTHER <br /> DISTANCE TO NEAREST SEPTIC TANK CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL FIELD _�� SELL PUBLLQC :_ ESTIG'`L3ELL <br /> I PROPERTY LINE -� PRIVATE DOMES TIC « -�ONSCTI�N�P_yCIFICATTONS O <br /> TYPE OF l Excavation <br /> INTENDED USE WELL - <br /> Cable Tool Da. .of Wel <br /> Industrial %'i Drilled Dia. of Well Casing fS <br /> Domes ^____ Gau of Casing <br /> F r Driven g� <br /> Domestic/public Depth 01 Grout Seal <br /> Gravel Pack P ,,-i <br /> t Irrigation Rotary Type hof Grout <br /> Cathodic Protection . ^ r� Others Information <br /> Other ���_ <br /> F Disposal I Surface Seal Installed 13 <br /> Geophysical t <br /> 4 Fps <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> } if <br /> State Work Done _ <br /> PUMP 'REPLACEMENT: <br /> 4' /-"`-State Work Done ' <br /> PUMP .REPAIR: i , <br /> . .� Approximate Depth <br /> DE5 TRUCTION OF WELL- Well Diameter <br /> Describe Material and Procedure <br /> lth <br /> ricl <br /> m ] with all laws and regulations of '.�he San LoWithal linaFIFTFENtDAY! <br /> I hereby agree to copy Well'-construction. <br /> and the State of California pertaining to °� regulating <br /> San Joaquin Local Health Distric <br /> after completion of my work on a new well, ° uttin the• well in use. The above <br /> REPORT of the well and notify them before p g <br /> i true to the best of my knowledge and belief . I WILL CALL FO <br /> information SR A GROUT INSPECTIOI <br /> WELL DRILLERS <br /> PRIOR TO GROUTI AND A F NAL NS E N. t ' TITLE '� �° '�� <br /> jSIGNED (DRAid PLOT Pi�AN ON REVERSE SIDE) <br /> FOR DEPARTMENT TJSE ONLY p <br /> DATE b <br /> ` PHASE I w <br /> AP- p ATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTIONINSPECTION BY DATE <br /> INSPECTION BY 11 DATE <br /> 6,177 2M <br />