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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. Hazelton Ave. ,, Stockton, Calif. <br /> FOk <br /> FFICE <br /> Telephone:`� . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -6 <br /> SUED Date Issued <br /> ISPERMIT <br /> THPERMI <br /> T EXPIRES 1 <br /> YEAR <br /> FROM DATE IS <br /> In Triplicate) <br /> construct <br /> (Complete to <br /> k Application is hereby made to the San Joaquin LocalHealth lication ismadetrict inrcom fiance with San Joaquin <br /> and/or install the work herein described. This app <br /> p <br /> County Ordinance No. 1862 a�jdthe Rules and FRegulations of the San JaquiL3oc�a1 Health District. <br /> N=` � v`r" f CENSUS TRACT <br /> G JOB ADDRESS/LOCATION <br /> r Phone <br /> f Owner's Name rr <br /> City ' J�o <br /> E4 <br /> I Address. <br /> License # !S�3 7 hone 4, <br /> Contractor's Name, <br /> r� <br /> j F.. <br /> _I E OF WORK (Chec ) : I DEEPEN -/ / RECONDITION_/� DESTRUCTION /? <br /> i� <br /> TYPE kNEW WELL PUMP INSTALLATION II PUME? REPAIR ISI PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELI�CONSTRUCTION SPECIFICATIONS <br /> k INTENDED U.M. OF WELL <br /> Cable Tool Dia. of Well Excavation <br /> F Indus trial: •n. Dia. of Well Casing <br /> rly-dte Drilled <br /> Domestic/p.. Driven ', Gauge of Casing <br /> Dome stic/pub:lie <br /> Gravel Pack- "Depth of Grout Seal { <br /> ' - Irrigations Rotary Type of Grout <br /> Cathodic Protection Other Other Information <br /> Other <br /> Disposal , <br /> Surface Seal Installed B <br /> Geophysical <br /> C <br /> PUMP INSTALLATION:' Contractor . H.P.. <br /> i TYPE of Pump -µc <br /> G <br /> PUMP REPLACEMENT: / / State Work,Dorie <br /> PUMP .REPAIR: -State 'Work Done 1 <br /> Approximate Depth <br /> IDESiRUCTION OF WELL: Well Diameter i <br /> Describe Material and Procedure <br /> ithe San Joaquin <br /> rYI hereby agree to 'comply with all laws and regulations 0Well-construction.LoWithinaFIFTEENtDAYS <br /> , and the State of 'California pertaining to; or reg g <br /> a new well', I will furnish the San Joaquin Local Health Distiict <br /> after completion of my wa,rk on <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 m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ' PRIOR TO GROUT NG AND A FINAL I PE - IO ITLE 2 - <br /> SIGNED �' <br /> RA -PLOT PLAN ON RE SE SIDE). ' <br /> ,FOR DEPARTMENT USE ONLY- <br /> , <br /> PHASE I • DATE <br /> ' APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: p q;/F INSPECTION <br /> PHASE II GRO INSPECTION INSPECTION BY ATE <br /> INSPECTION BY DATE <br /> i 11-77 <br /> 24 <br /> F U 1Lm Rev. 1-74 <br />