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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I. Telephone: (209) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THISIPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> I <br /> Application is hereby made to 'the San Joaquin Loalicatian ist <br /> tmade inrco pliancea permittwithnSanuJoaqui.n <br /> and/or install the work herein described. aPP <br /> County Ordinance No. 1562 and,,-the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRAC - aG I� CQ <br /> JOB ADDRESS/LOCATION 73 <br /> I1 Phone Ca-, ,( <br /> Owner's Name <br /> Address -' <br /> s,' , License [g3 .Phone 'C/ <br /> Contractor's Name i <br /> • NEW WALL /� DE /�I RECONDITION I I DESTRUCTION <br /> ' <br /> TYPE OF WORK (Check) . P� REPAIR / '/ PUMP REPLACVE Q <br /> PUMP INSTALLATION I�� O <br /> Other •`I I <br /> r PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWAGEDISPOSAL DISPOSAL FIELD�jtl-'CESSPOOL/SEEPAGE PIT - i•OTHER <br /> PUBLIC DOMESTIC- WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL <br /> k INTENDED USE �, <br /> l Dia. of Well Excavation <br /> Industrial ri Cable Tool_'-' <br /> Drilled Dia. of Well Casing _ <br /> A----Domestic/private7! Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation �_ : r Gravel Pack Depth; of Grout Seal, <br /> I rotary; Type of Grout r d <br /> Cathodic Protection ^ <br /> Disposal ... Other/' Other Other Iti'fo1. <br /> rmation — <br /> ', Surface Seal Installed B' ' <br /> Geophysical <br /> PUMP.MINSTALLATION: Contractor <br /> Type Cof Pump <br /> i <br /> ' <br /> PUMP REPLACEMENTState Work bone <br /> : I Ix <br /> PUMP .REPAIR: E7 . State Work Donee i <br /> + Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter and Procedure <br /> Describe Material <br /> I hereby agree to comply with all laws'{odor�gls : welleSan oaquin Lo <br /> .constructs.on. Withi.nocal aDistrict,lth <br /> FIFTEEN DAYS <br /> I <br /> and the State of California pertaining t regulating <br /> cal <br /> after completion of my work on a new well Iwill <br /> beforep <br /> furnish <br /> uttingathe .wellnin uuse.HeThe habove <br /> District a <br /> WELL DRILLERS REPORT of the we11 and not y them <br /> info tion is true to the best �myfknowledge :and belief. I WILL CALL FOR <br /> GROUT INSPECTION <br /> e <br /> PRIOR OUTING AND E TITL <br /> a i <br /> SI , <br /> W.•:P7;, T PLAN ON RE FrRSE SIDE) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 7 lZg' <br /> APPLICATION ACCEPTED BY <br /> ` ADDITIONAL COMMENTS: I PHA, II INAL INSPECTION <br /> PHASE II GROUT INSPECTION -`r� INSPECTION BY DATE <br /> INSPECTION BY !. DATE <br /> ` r 3/76 2M <br /> v H 1426 Rev. 1-74 - <br />