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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> •FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, <br /> Calif. <br /> Telephone: (209) 466-6781 permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THISpERMTT EXPIRES l YEAR FROM DATE ISSUED Date issued <br /> (Complete In Triplicate) <br /> rict rt <br /> Application is hereby made to the San Joaquin <br /> Local <br /> plicati.onDis ,made inco pliancewith Sanuct Joaquin <br /> and/or install the work herein Thisapp <br /> p <br /> County Ordinance No'`. 1862 and ,the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> ,TOB ADDRESS/LOCATION 4573-A Farm St. <br /> - <br /> Phone 466-3911 <br /> Stockton,Unified School District <br /> Owners Name i <br /> City Stockton <br /> Address 1149 N. EI Dorado 5t. <br /> World Enterprises License if�65964 Phone 931=2974 <br /> Contractor's Name I' <br /> DEEPEN I I RECONDITION_/ / DESTRUCTI N <br /> TYPE OF WORK (Check) : <br /> NEW WELL I P REPT c ME <br /> PUMP INSTALLATION / / PUMP REPAIR/ / <br /> 0th lI <br /> � PIT PRIVY <br /> DISTANCE TO NEARESTSEWER LINES <br /> : SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD `1 <br /># DOSTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLCONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> In <br /> y Dia. of Well Casing , - <br /> Domestic/private Drilled <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Type of Grout <br /> Cathodic Protection Rotary Other Information <br /> -Disposal Other <br /> Surf ace Seal Installed <br /> Geophysical B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: /_7_ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> _ <br /> Describe Material and Procedure Fill with neat cement pour ca over dosing <br /> 3 feet below existing grade <br /> i I hereby agree to comply with all la s to ore rulations ofthe San Joaquin LoHealthcal <br /> regulating well'construction. Wi.thinFIFTEENtDAYS <br /> and the State of California pertaining <br /> after completion of my work- on a new well Ithemlbefo esputtingathe_wellninouse.HeTheh above a <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 G TING AND A FTN IN PECTION. TITLE co-Owner <br /> SIGNED <br /> I <br /> „ D ' VERSE SIDRAWPLAN ON E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION 'ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHA NSPECTION <br /> PHASE II G INSPECTION INSPECTION BY DATE 2- <br /> - <br /> INSPECTION BY �� BATE <br /> 3/76 2M <br /> F R 1426 Rev. 1-74 -- - <br />