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SAN JOAQUIN LOCAL HEALTH DISTRICT �7 <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOE.OFFICE USE: Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit to construct ? <br /> cal Health <br /> Application is hereby made to tdescribed. Thise San Joaquin oapplication istrict fmade inrcomplian1eHealthwith SDistri.ct. <br /> and/or install the an Joaquin� <br /> work heard s <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local ` <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> e � <br /> Phone <br /> Owner's Name !� ' <br /> City - 1 <br /> Address • <br /> License #,33 ff Phone - <br /> Contractor's Name <br /> RECONDITION_-/ / DESTRUCTION /- <br /> E TYPE 'OF WORK (Check) : NEW WELL DEEPEN PUMP REPAIR / I PUMP REPLACEMENT /7 v <br /> PUMP INSTALLATION '( I <br /> Other <br /> C SEWER LINES r PIT PRIVY _��' <br /> DISTANCE TO NEAREST: SEPTIC TANKp CESS- 0(SEEPAGE PIT `�OTHER T` <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINQ'PRIVATE DOMESTIC WELL PUBLIC .DOMESTIC WELL <br /> INTENDED USE TYPE OF' WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Driven <br /> k Domestic/private --~- Drilled Gauge of Casing <br /> k Domestic/public . ' <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> E RotaryTyp_eo .�Gr�aut <br /> Cathodic-Protection_ _ _. :-� - Other Information <br /> " ]]isposal - Other <br /> Geophysical Surface Seal Installed B <br /> NO ?AII <br /> PUMP INSTALLATION: Contractor O H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.REPAIR: / / State Work. Done <br /> Well Approximate Depth _ <br /> DE5•TR[lCTION OF WELL: Describemeter Material and Procedure <br /> ree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I hereby a g <br /> and the State of California pertaining to or wxgllfu=ngshethe SantJoaquin.LocalhHealthin TEEN District <br /> AYS <br /> after completion of my work an a new well, I <br /> ' WELL DRILLERS REPORT of the well and notithem <br /> andbefore <br /> belieftt�I WILL CALL FOR A GROUTThe <br /> INSPECTION <br /> � <br /> information is true to the es o my10knowledge <br /> PRIOR TO UTING D A I TITLE r- , <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> r �— <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: =PHASE I /FiN INSPECT ON g <br /> PHAS GRO T INSPECTION INSPECTION BY DATE G l <br /> INSPECTION B DATE �?� { <br /> 1177 <br /> V-14 167Fi Re 1-74 _ ---- <br />