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/ SAN JOAQUIN LOCAL: HEALTH DISTRICT . U'� <br /> CA Stockton, <br /> FOF.OF CE USE: 1601 E. Hazelton Ave: , <br /> Telephone 466=6781 <br /> (209) , _ Permit <br /> APPLICATION FOR WELL'� CONSTRUCTION OR PUMP PERMIT � <br /> THIS PERMIT EXPIRES 1 YEAR-FROMDATE ISSUED , <br /> Date issued � <br /> (Complete.:In Triplicate) permit to construct <br /> s a licati'on is made in compliance with- San <br /> Distrit Joaquin <br /> A lication is hereby made to the San Joaquin Local. District for a p th <br /> ,pP <br /> and/or install the work herein described. k <br /> i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local- Heal <br /> RACT <br /> IF CENSUS T <br /> 1111 <br /> :3 Coot <br /> JOB ADDRESS/LOCATION 4,1- <br /> • `��' �On � >�{�' ..r�.....-----.••— Phone <br /> Owner's Name <br /> City <br /> Address 'ishone <br /> License 4�,G <br /> Contractor' s Name i <br />�t RECONDITION / / DESTRUCTION /F7 <br />' .TYPE OF WORK (Check) : NEW WELL / DEEPEN I I-, pUREPLACEMENT I <br /> PU2T FiNSTALLATION / / PUMP REPAIR / <br /> Other <br /> SEWER LINES PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPDSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS_ ^ \ <br /> TYPE OF WELL <br /> INTENDED USE � Dia. of Well Excavation <br /> Industrial -Cable Tool ing <br /> Drilled Dia. of Well CasC <br /> Domestic/private Gauge of Casing <br /> Driven <br /> Domestic/publicDepth of Grout Seal <br /> t Irrigation Gravel Pack P <br /> Rotary Type of Grout <br /> Cathodic .protection Other Other Information <br /> Disposal' Surface Seal Installed By* <br /> Geophysical 1 <br /> PUMP INSTALLATION: Contractor H.P: <br /> Type of Pump <br /> f PUMP REPLACEMENT: /i State Work Done <br /> PUMP .REPAIR: State Work Done Q <br /> # Approximate Depth <br /> Well Diameter -----'" <br /> DESTRUCTION OF WELL., , <br /> Describe Material and Procedure <br /> IIIct <br /> lth <br /> I hereby -agree to comply with all laws and rein <br /> of thSan joauIn <br /> aFIFTEENtDAYS <br /> and the State of Cali:fornie <br /> �a pertaining to or $ulating well <br /> after completion of my work an a new well, I will furnish the San Joaquin Local <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use... The above ef. I WILL CALL FOR A GROUT INSPECTION <br /> F information is true to the best of. my knowledge <br /> PRIOR TO GRO I AND rA FINAL INS IO TLE ', : <br /> I. SIGNEDW P OT PL N RE SE SIDE) <br /> k (` R DEPARTMENT USE ONLY <br /> PHASE I li DATE 0_d 71 <br /> I APPLICATION ACCEPTED BY <br /> i ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY �� _ DATE /r.,�V <br /> INSPECTION 'BY f1 DATE <br /> # ,�7 7 2M <br />