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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAfOFFICE USE: /16.01 E. Hazelton Ave. , Stockton, <br /> Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -_:i6 <br /> 367, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued 7-� '� <br /> (Complete In Triplicate) permit to construct <br /> R application is made in compliance with San Joaquinf <br /> ApgllcatianRis hereby made to the San Joaquin Loc compliance District or a Lacal Health District. <br /> and/or Install the .work herein described. This app <br /> County Ordinance-I-L 1862 aa� the Rules and Regulations of the San Joaquin <br /> ,e I osR CENSUS TRACT <br /> JOB ADDRESS/LOCATION Phone <br /> Owner's Name a <br /> City uAj <br /> Address' - ' <br /> I. D License # _ Phone ; <br /> Contractor'a Name <br /> t � <br /> ,�/ REG01dDxTION /_7 DESTRUCTION /_7 <br /> TYPE OF WORK (Check) :4 NEW WELL �► DEEPEN /� .� <br /> f <br /> Pump INSTALLATION j±�PUW RFpAIR / / PUMP REPLACEMENT �T <br /> Other j / <br /> -` <br /> l SEWER LINES fes- PIT PRIVY O <br /> DISTANCE TO ,NEAREST': •SEPTIC TANK foo CESSPOOL/SEEPAGE PIT 1SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> o, ;PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> � TYPE OF WELL CANSTRUCTION SPECIFICATIONS <br /> ► INTENI}ED <br /> E. Dia. of Well-,Excavation a" - <br /> Cable Tool -•.` . - <br /> Industrial , --~-Drilled,,., <br /> Dia.•-of Weil Caein� <br /> ' ar-=7_ Ga - <br /> x �s-�omes.tic�P uge rof.�C-- S. <br /> - Domestic/public 1 ,.'-D- -th of Grout Seal <br /> - _navel Pack <br /> "' P -- <br /> 3riigaftian o .; :'�o�tary o Type of Grout _ <br /> - Otheir <br /> Cathodic Protection s, Other Information <br /> Disposal <br /> } _ _-�•- . � � � Surface Seal Installs <br /> Geophysical. <br /> PUMP INSTALLATION: Contractor S v 3 H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT; jj State Work Done <br /> � PUMP `.REPAIR: / <br /> State Work Done - <br /> Approximate Depth —/P-.S � <br /> EST cTION OF WELL: Well Diameter <br /> Describe Materia3�and ProcedCu e J �E r+J��"_f�'� � r <br /> e tYf [ /fir G, <br /> � with all laws and regulations of the San Joaquin Local Tlealth District <br /> 1 I hereby agree to cAYS <br /> omply11 Within <br /> I and the State of California pertaining to or reglatingating wethecSai Joaquin•Local Health District <br /> }, <br /> after completion of my work on a new well, I will <br /> WELL DRILLERS REPORT of the well and notify them <br /> beforend putting WILL CALL FOR A GROUT eINSPECTION <br /> information is true to the-best.of• my .kno 8 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE <br /> SIGNED 77 DRAW PLOT PLAN ON REVERSE SIDE <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I DATE " <br /> APPLICATION ACCEPTED BY ° <br /> ADDITIONAL COMMENTS: - PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE -1 �- <br /> INSPECTION BY "� DATE <br /> 1-74 2M <br /> "'4 E H 1426 Rev. 1-74 <br />