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FOR, a- • SAN JOAQUIN LOCAL HE <br /> OFFICE US E: 1gOY E. Hazelton HEALTH DISTRICT <br /> r "1_ Ave., Stockton, Calif. <br /> Telephone; _ <br /> APPLICATION FOR WELT, CONSTRUCTIONORPUMP PERMIT Permit No. <br /> M1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is Hereby made to the San (Jomp a eLocal Health <br /> Date Issued �- <br /> and/or install the h Di <br /> work herein described. This- application IsmadeInrcompliancea permit twithnSanuJoa Joaquin <br /> E '. County OrdinancerNo. 1862 and the Rules and Regulatians o£ the San Joa uin Lac <br /> E q <br /> .JOB ADDRESS/LOCATION q b(9(o F 4 al Health Digtrict. <br /> E � i <br />, ,Owner s `Name 1 CENSUS TRACT <br /> ` iR OAA <br /> �lCitio� DMP � y <br /> Address 3Phone ' 'Z <br /> 3� A)r�� u�Nu 3 <br /> Contractor's Name City �y / P <br /> LIC <br /> e <br /> License UZ Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> � DEEPEN DESTRUCTION /"] <br /> /_� RECONDITION /? k <br /> PUMP INSTA#,LATION '/ / PUMP REPAIR <br /> Other Z:77 --- /? PUMP REPLACEMENT /7 <br /> DISTANCE TON <br /> SEP { <br /> EAREST. ; TIC TANK �pj SEWER LINES <br /> SEWAGE DISPOSAL FIELD �' - D�'. P��,PRIVY <br /> PROPERTY LINE - PRIVATE D[}1+�ES:TICSWELI,!SEEPAGE PIT-*� PUBLIC DOMESTiOTHER <br /> INTENDED USE TYPE OF WELL C WELL <br /> Industrial r CONSTRUCTION SPECIFICATIONS <br /> Domestic �,.^ Cable Tool' <br /> Dia. of Well Excavation, <br /> /private Drilled 0` <br /> Domestic/public Dia.. of Well Casin_ ' ` <br /> Irrigation - Driven Gauge of Casing ��,, <br /> Cathodic Protection Gravel Pack Depth``of-Grout,Seal =---� <br /> ` <br /> _ Disposal _ � Rotary _ - 'Type of Grout " <br /> Other � •. Other Information <br />_ _•_ Geophysical.. .--=---�. <br /> Surface Seal Installed B i <br /> PUMP INSTALLATIONa <br /> ContractorL_21t i` <br /> 0Ch <br /> Type. of Pump Stagy�3 1'P <br /> - H'P. 1 <br />'UMP REPLACEMENT: State Work DoneA <br />'UMP :REPAIR; � •, . ,,,, ,� L <br /> / / State Work DoneES-TRUCTION QF WELL: Well DiameterDescribe Material and Proce . Approximate Depth'hereby agree to comply with all lawsOrad regulatan Joaquin Local Health <br /> nd the State of �California pertaining to or regulating well "•construction. Within FIFTEEN DAY <br /> Eter completion of my work on anew well, I will furnish the San Joaquin Loc District <br /> ELL DRI PART S <br /> t wel and notify them before putting. the..well in.use..HealthDista t <br /> zfo t n i <br />;IOR a of 'knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> LGNED ION. <br /> TITLE vim' <br /> s (DRAW PLOT PLAN ON REVERSE STD <br /> ;� ----------- <br /> AAS yf T'0 DEPARTMENT USE ONLY <br />!PLICATION' ACCEPTED BY C� l� <br /> DITIONAL COMMENTS: DATE <br /> PHASE I GROUT INSPEC 'ION <br /> SPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION� � By/ c� DATE <br /> E H 1426 Rev. 1-74 <br />