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-�-r _ ��11 <br /> I�. 7/� SAN JOAQUIN LOCAL HEALTH DISTRICT W <br /> FOE DFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. 77 fl3 p <br /> Telephone: (209) 466-6781 Su <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lam= <br /> I Date Issued2--4— <br /> (Complete <br /> 4- <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM.:DATE ISSUED � <br /> (Complete In Triplicate) ' <br /> Local Health District for a permit to construct <br /> o the San Joaquinn <br /> k made t . Joaquin <br /> Application is hereby is <br />{ <br /> and/or install the -work here in hesRulesdandTRegulations ofhis nthe Sane.ToaquinpLoca1 Health SDistrict. <br /> i <br /> County Ordinance No. 1862 aria t 3.. <br /> -'114 f,// CENSUS TRACT <br /> JOB ADDRESS/LOCATION •Mo✓ iC <br /> Phone <br /> Owner's Name T <br /> City <br /> Adaiess FF <br /> i License # --Phone <br /> Contractor's Name <br /> + � i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN %�/ PRECONDITION / / DESTRUCTION — .. <br /> PUMP INSTALLATION /?CI PUMP REPAIR.--�.PUMP REPLACEMENT . /- <br /> Other E77 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> STIC WELL <br /> PROPERTY LINE -PRIVATE DOMESTIC WELL CONSTRUCTION SPBLIC ECIFICATIONS <br /> INTENDED USE:S TYPE OF WELL <br /> ' Industrial "" - f ' Cable Tool WDia. of Well Excavation <br /> Drilled Dia.sof Well asin.g - <br /> Domestic/privateDriven <br /> Domestic/ '° 'Gauge"" oCasing <br /> p_ubli_c. - � <br /> 'Irgation ` . Gravel Pack Depth of Grout Seal <br /> T e •of Grout <br /> Cathodic Protection Rotary Ater information <br /> Disposal Other <br /> Surface Seal- Installed B <br /> Geophysical. <br /> PUMP INSTALLATION: Contractor H.P. S_GCJ <br /> Type of Pump <br /> PUMP REPLACEMENT: / ./. State Work Done � <br /> Done <br /> PUMP <br /> PUMP .REPAIR: State Work <br /> Approximate Depth <br /> 'DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> agree to comply with all laws and regulations of the San Joaquin <br /> - Local Health District <br /> I hefeby agr P YWithin <br /> ( AYS <br /> and t e State of California pertaining to or regulatinfurngshethecSantidaquin.Local Health TEEN District , <br /> k, afte7completion of my work on a new , <br /> WELL DRILLERS REPORT of the well and notify them before putting the•well in use. The above <br /> f <br /> information is true to the best y. knowl d-geed belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS IO TITLE <br /> SIGNED ' <br /> D W PL' LAN 'ON RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> o <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE I 6 0I ECIDN i DATE /'O.-/ <br /> T <br /> INSPECTION BY ATE_ INSPECTION BY — <br /> 3/7�f <br /> � . E H 1426 Rev. 1-74 — <br />