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;, r�g RJpU' OCAL :HEALTH DISTRICT <br /> Fpg� CE" USE; 1 �1 "N Ha�'e1I "Ave', Stockton, Calif. <br /> �'� �1 1"j Tele_pho e:, '(209)_466-6781 <br /> �, PLICATION-,V�R� WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74-- <br /> •r'' 1 ` ASSUEDIIate I�asued,�� 9-7 <br /> THis. PER S =l YEAR FROM DATE I <br /> dpi?, �V let e"In Triplicate) d �o <br /> A lication is hereby made �:h San Joaquin Laca1'HeaSt ►T:D .strict €or a Fe tetwith S muct <br /> Jaaquini <br /> County ordinance No18b2. and th <br /> pp This ,application is nade:)&Wtottpli c <br /> and/ox install the work her n. described:;,-_ <br /> . e Rules •and :Regulations-;of .the:tSsn:Joaquin Lotal)Hdalth District'.. II <br /> --.--.._ A4 gyp. ��-d�� ,�do7++i <br /> CENSUS-TRACT <br /> JOB ADDRESS/LOCATION <br /> +Phone <br /> Owner's Name �!/_ <br /> Address fD <br /> 1 _ ... . ,. .,. .. ,_. �- .•-W� Citq G S�J�., <br /> Contractor's Name # ..`-9-0 Phone en- <br /> License �- 7J <br /> P$-QF WORK (Check): NEW WELL..L� 'DE PP RECONDITION• /­PUMP, <br /> - DESTRUCTION in <br /> PUMP INSTALLATION / / PUMP REPAIRS F7 PUMP..REPLACEMENT / I <br /> "] <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER. LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLDOMESTIC WLL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial X Cable Tool ' . Dia:of-Well Excavation <br /> I� Domestic/private Drilled ' Dia: of Well 'Casing � �1 <br /> Domestic/public DrivenGauge of Casing 0 <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> e of .Grout <br /> Cathodic Protection Rotary ' mer Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed By: . <br /> _^...__ r <br /> F, v <br /> PUMP INSTALLATION: <br /> Contractor. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done. <br /> E PUMP '.REPAIR: /7 State--Work Done`" <br /> G VE&IRUCTI6A OF WELL: Well Diameter Approximate Depth <br /> Describe-Material and Procedure <br /> I I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> f after completion of my work on a new.well,, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <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 FINAL INSPECTION« .. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 3Y �� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE IIF NAL INSPECTION <br /> } INSPECTION BY %! DATE 7 y <br /> 4 INSPECTION BY _ DATE <br /> F <br /> 1-74 2M <br /> ;«E H 1426 Rev. 1-74 - <br />