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E USE. SAN <br /> FO&;OFFICE JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F <br /> Telephone: (209,) 466--6781 <br /> APPLICATION FOR WELL CONSTRbCTION OR PUMP PERMIT Permit No. ,? Tl id <br /> THIS <br /> �- <br /> THI5 PERMIT EXPIRES l YEAR FROMDATE ISSUED <br /> Date Issued �- <br /> Application is hereby- (Complete In Triplicate) - <br /> and/or install the work hereintdescribedan .��uThisin aapplicatianHealth nistrict for a <br /> COtY Orn ce No. 1$62, and tha Rule and permit to construct <br /> is made 3n compliance with Sen Jar�quir <br /> eco /L gulations of the San Joaquin Local Health District. <br /> JOB �/LOCATION %^Tel <br /> 1CENSUS TRACT <br /> Owner's Name !t5 <br /> Phone <br /> f Address Q <br />} i <br /> Contractor's Name City <br /> d �''Yl2 d?s' f4_� <br /> License <br /> Pho ne9 --T2_/[} <br /> TYPE OF WORK (Check): NEW WELLDEEPEN ' - . <br /> /7 RECONDITION _ <br /> PUMP INST I /LATION / PUMP REPAIR DESTRUCTION <br /> / PUMP REPLACEMEN <br /> Other %f <br /> DISTANCE TO NEAREST: f <br /> SEPTIC TANK SEWER LINES Y W --"� .-`""�-g <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD --- E <br /> ` CESSPOOL/SEEPAGE FIT~: LfOTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC° ,Lf PUBLIC-DOMESTIC WELL <br /> r INTENDED USE TYPE OF WELL, <br /> Industrial " . L CONSTRUCTION SPECIFICATIONS <br /> Domestic Cable Tool � Dia: of Well Excavation � <br /> /private. Drilled � ' , c <br /> Domestic/public __2L_ x Dia. Well Casing t <br /> _ _`Irrigation --�. Driven Gauge�of Casing 7 <br /> Gravel Pack y° Depth oGrout SealCathodic Protection Rotary <br />.Disposal Type of 'Grout -- t <br /> C i <br /> �- <br />_,_____Geophysical Other Other informatio <br /> Surface Seal Installed By: <br /> PUMP INSTALLATIONS <br /> Contractor � <br /> Type of Pump <br /> _. - H.P.. <br /> PUMP REPLACEMENT: a4"; ,` <br /> State Work Dene � <br /> PUMP :REPAIR: State Work Done <br />)E&TRUCTION OF WELL: Well Diameter <br /> 01 <br /> y Appr ximate Depth <br /> De ribe Mate and Proc dare � <br /> �� a <br /> C hereby agree to comply with all laws and regu3ativns of t e San Joa uin Loca s <br /> tnd the State of California pertaining tofor regulating well .. <br /> r <br /> q 1 Health District <br /> tfter completion of my work on a new well; �.I will furnish the San Joaquin Local hHealth District a ,F <br /> TELL DRILLERS REPORT of the well and•nell,;-'themwit before <br /> nformation is true to the best .of Putting. the .well in.use.... .The above <br /> RIOR TO GROUTING AND A FINAL INSPECTIp no�rledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IGNED 1_ <br /> U <br /> P E <br /> REVERSE SIDE <br /> I ' - . <br /> RASE R DEP MENT USE ONLY <br /> PPLICATION ACCEPTED BY i ~ { <br /> DDITIONAL COMMENTS DATE ' <br /> PHASE II I QUT INSPECTIO k <br /> 1SPECTION BY .�' ATE PHAS I NAI: INSPECTZO <br /> o l <br /> INFECTION"BYr- , .DATE <br /> Rev. 1-74t,G <br /> e ,E, }1426 -Ap._i <br />