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SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> +, <br /> Telephone: (209) 466-6181 Permit- No. 7ti ,cJsa <br /> APPLICATION FOR WEL&CONSTRUCTION OR PUMP PERMIT 76Y r6`f <br /> 7= 7 <br /> THISDate issued. PERMIT EXPIRES 1 YEAR FROM SATE ISSUED ---�-- 6 � <br /> s (Complete In Triplicate) . for a permit <br /> Application is hereby made to the San Joaquin Local 11calth District in compliance twith nSan Jaaquir <br /> struct <br /> Apt' plication made <br /> and/or install the work herein described. This app . <br /> County prdinance No. 1862 and;the Rules and Regulations of the San Joaquin Local Health District. <br /> f r---- <br /> ENSUE TRACT <br /> JOB ADDRESS/1 �� �� <br /> Phone ' <br /> .Owner's Name <br /> J <br /> City , . <br /> "Address <br /> f License • Phone 9� -" 1® <br /> Contractor's•Name % J <br /> I <br /> i TYPE OF WORK {Check): NEW WELL DEEP /7 <br /> RECANDITIONfDESTRiTCTION I=T <br /> N TION /� PUMP ,REPAIR % PUMP REPLACEMENT 17 <br /> Other I <br /> SEWER LINES <br /> PRIVY= <br /> DISTANCE TO NEAREST: - SEPTIC TANK /D�f" -�—. '- <br /> SEWAGE DISPOSA�IELD� CESSPOOL/SEEPAGE PIT - <br /> OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WEL-L. `� PUBLIC DOMESTIC WELL <br /> _ TYPE OF WELL --CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool -Dia. of Well Excavation y . <br /> Industrial <br /> Drilled Dia. of Well Casing s <br /> �[ Domestic/private _, d <br /> Domestic/public Driven Gauge of Casing :p <br /> Gray.er.P.ae.k,� Dep hTof-Grout-SeaI <br /> Irrigation <br /> Type of Grout <br /> Cathodic Protection = Rotary Other Information <br /> Disposal Other _� <br /> Surface Sear Installed. -By.- <br /> Geophysical <br /> PUMP INSTALLATION: Contractor ! H.P. <br /> Type of Pump <br /> ,PUMP REPLACEMENT: / / State Work Done <br /> pump 'REPAIR: �/ <br /> State Work Done <br /> Approx to De th <br /> DES1TRUCTION OF WELL: WelllDiameter <br /> Desc_ ibe Material and P cedure <br /> l Sa Joaquin <br /> I hereby agree to comply with 1 laws and regulatiowelleconstruction.LoWithinHealth <br /> FIFTEENDistrict <br /> DAYS <br /> ,and the State of California pertaining to or willfurnish <br /> regulating <br /> F <br /> after completion of my work on a new well Ithemlbeforesputtingathe�well. in use..H�Theh 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED (DnV P T ON REVERSE SIDE .�---- <br /> FOR DEF TMENT USE ONLY <br /> PHASE IDATE <br /> APPLICATION' ACCEPTED BY �^ <br /> ADDITIONAL COMMENTS: PHASE IIT FINAL INSPECTION <br /> . PHASE II GROUT INSPECTION DATE <br /> 16 <br /> ',INSPECTION BY DATE INSPECTION BY. <br /> GO <br /> V _ I_1A <br /> 0 <br /> r' <br />