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v SAN JOAQUIN LOCAL�H'EALTH DISTRICT - ' <br /> .+FOFi,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r: <br /> Telephone:: <br /> p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP:PERMIT Permit No. A-l`-777kl <br /> 7� 336 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE';ISSUED Date Issued <br /> r (Complete In Triplicate) <br /> ' Application is. fiereby,'mad'e to-the San Joaquin Local Health District for. a permit to construct <br /> and/or install lhevibrk herein described. This application is made. in. compliance with San•Joaquin <br /> r Cour:ty Ordinance No;� 1862 and. the Rules and Regulations of the San-Joaquin.,Local Health District.. <br /> JOB ADDRESS/I.00AT ON DIU CENSUS-TRACT <br /> Owner's Name. <br /> one <br /> Address. �d� C RPS f�R'trt flIU MflC WDo D LE City' <br /> Contractor's. Name License #2op, Phone�l-pA <br /> TYPE OF -WORK•-(Che ck)"or-NEW"WEDI;' . —DEEPEN , "".RECONDITION -DESTRU TIO <br /> PUMP INST�TION. / °// PUMP REPAIR -/-7 PUMP REPLAcEMBI+IT 17 <br /> 7 <br /> Other / <br /> o <br /> DISTANCE TO NEAREST:. SEPTIC TANK�oeLfl � SEWE& LINES r PIT PRIVY �- <br /> SEWAGE: DISPOSAL. FIELD. CESSPOOL/SEEPAGE PIT' OTHER <br /> PROPERTY-tINE- -- PRIVATE DOMESTIC WELT:` PUBLIC DOMESTIC. WELL � <br /> INTENDED USE, TYP& OF WELL �. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> �-- Domestic/private- Drilled, 'Dia,. of Well Casing t <br /> Domestic/public.:- Driven , Gauge. of- Casing. ; <br /> Irrigation. 'Gravel- Pack Depth of Grout Seal " <br /> Cathodic Protect on ^ �C Rotary's Type of Grout <br /> -r--Disposal: Otber,. Other. Information-. <br /> Geophysical Surface S <br /> _ eal I ns:talled, 'By, _.....,.,_ <br /> PUMP INSTALLATIONt Contractor f <br /> Type:. of Pump <br /> 'P,UMP REPLACEMENT": / / State. Work: Done — -- -• - - (o` �� <br /> PUMP .REPAIR: /? State. Work. Done <br /> DESTRUCTION OX:WELL:, Well, Diameter: ` Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree.. to. comply with. all lawsand regulations ,of the San. Joaquin. Local,..Health District <br /> 4nd: the State of" California pertaining to or regulating well''constructions:. Within FIFTEEN, DAYS <br /> 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 imd-:notify, them. before putting, the:.wel1= in-,.use.... The, above} <br /> ' information is true: to,,the,.best• of. my., knowledge and 'belief. I WILL CALL- OR'A GROUT INSPECTION <br /> PRIOR TO GROU G.'AND; A.PIN INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PiHASE I °� <br /> ,APPLICATION ACCEPT r-BY' C� Tg � <br /> 'ADDITIONAL CO y ; <br /> Pw 11 GAOUT INSPECTION ` P S I INSPECTI <br /> INSPECTIO DATE. INSPECTTO�T BY DATE <br /> f E H 1426 Rev. 1-74: - "r. 3� -2M <br />