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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08 OFFICE USE: 1.601 E. Hazelton Ave. , <br /> Stockton, Calif <br /> I Telephone; (209) 466-6781 Permit No. /7? >" <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ------"'(r�i� <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued _�a <br /> k (Complete In Triplicate). <br />' Local Health District for a permit to construct <br /> Application is hereby made to the San Joaquin with. I <br /> ari Joaquiu <br /> and/or install the work herein described. This application is made <br /> uin Loc <br /> County Ordinance No. 186aleHealthSDistrict. <br /> ,2,. and the Rules and Regulations of the an q <br /> CENSUS TRACT <br /> t JOB ADDRESS/LOCATION.. W <br /> Phone <br /> k Owner's Name jf <br /> City <br /> Address <br /> License. ��. Phone... <br /> Contractor's Name a � Y <br /> liz <br /> STRUCTION <br /> TYPE OF WORK (Check) :. NEW WELL / / DEEPEN / PUMPROEPAIRIINII P�EREPLACEMENT 17 <br /> — �`. <br /> PUMP�INSTALLATION / -- <br /> 0 ther / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t.-PIT PRIVY <br /> Q'1?` OTHER <br /> SEWAGE DISPOSALFIELD �- CESSPOOL/SEEPAGE PIT + <br /> PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE 1 --f 'TYPE OF WELL a �- <br /> ' Cable Tool Dia. of Well Excavation <br /> Industrial �_ <br /> Drilled Dia. of Well Casing <br /> Domestic/private,:, — Driven Gaugejof Casing <br /> Domestic/public „j. - ' <br /> -, Gravel Pack -DeptW'of Grout S.ea1 <br /> Irrigation .eQ # Rotary Type of Grout <br /> Cathodic Protection — y ' <br /> Information <br /> Other_- Other <br /> Disposal , 5 Surface Seal Installed By' <br /> Geophysical <br /> ll 101,PUMP INSTALLATION: Contractor /++► Cf -CIF H.p. '_� <br /> i <br /> 1 Y Type of Pump <br /> PUMP REPLACEMENT: ! / /� State Work Done <br /> ` State Work Done <br /> ! PUMP .REPAIR: � / /(( <br /> r 1 Approximate Depth <br /> DES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laps ttdoregelulatingationsowell"con truction.uinLoWithin aFIFTEEN tDAYS <br /> and the State of Cal.i'fornia pertaining g <br /> after completion of my work on a new well, I willhem bfurnisefore put eSthan <br /> ing hepwell iJaquin n use ..�eThehric <br /> above <br /> WELL DRILLERS REPORT of the well and notify <br /> information is true to the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> + PRIOR TO GROUTING AND A FIN �� INS�PECTION. TITLE <br /> a <br /> SIGiED - DRAW PLOT PLAN ON REVERSE SI <br /> } FOR DEPARTMENT USE ONLY �y <br /> PHASE I DATE <br /> APPLICATION ACCEPTED:°BY <br /> ADDITIONAL COMMENTS: ` PHASE IIIf/ INAL INSPECTION <br /> PRASE II GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY p�� DATE <br /> v l h,)A uoY,_ , 1—74 <br />