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Coir �� ,. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 �S �s-• ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I83 ?S <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE pate Isued <br /> ISSUED f ��—0�•--C)� <br /> (Complete In Triplicate) <br /> alDistrict <br /> ct <br /> Application is hereby made to the San JoaquinLocalication ismade in compliance <br /> witht to nSannJoaquin <br /> end/or install the work herein described. This pp <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local Health District. <br /> e'�c�t2.2S ✓ -�D'� o �ut^s CENSUS TRACT <br /> JOB ADDRESS/LOCATION 0- /:S� S. <br /> Phone <br /> Owner's Name -o &r m / ! { <br /> r City <br /> Address <br /> �. License _/ 77.hone 7- %74 <br /> 'Contractor's Name <br /> r, I <br /> F <br /> 7 _ <br /> I TYPE OF WORK (Check): NEW WELL / DEPEN / ON <br /> U REPAIR <br /> PUmEREPLACIEMEN�fI <br /> PUMP INSTALLATION / <br /> f Other. / / <br /> f, i � <br /> S PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> PRIVATE DO <br /> PROPERTY LINE .. MESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE j . PE OF WELL CONSTRUCT UV SPECIIONS <br /> FICAT <br /> t Industrial Cable Tool Dia. of Well. Excavation <br /> d Domestic/private Drilled Dia. of Well Casing <br /> omestic/public <br /> D <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Type of Grout <br /> { Cathodic Protection — Rotary Ocher Information <br /> Disposal Other e <br /> F Geophysical Surf ace Seal Installed,.By: <br /> i1 <br /> PUMP INSTALLATION: Contractor � <br /> � H.P. .cO r <br /> Type. of Pump <br /> I PUMP REPLACEMENT: /�/ � State Work Done n <br /> 1 pUMP '.REPAIR: LFState Work Done <br /> k Approximate Depth <br /> ES'TRUCTION OF WELL: Well iameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin L-the- well in.ocal HealthDistrictE <br /> WELL DRILLERS REPORT of the well and notify them befbeliefttil WILL CALL FOR A�GROUT INSPECTION <br /> information is true to the best of. know d <br /> PRIOR TO ARUTING AND A FINAL I I ITLE <br /> SIGNED DRA PLOT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE -71 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION- BY DATE <br /> INSPECTION BY i DATE <br /> € 1-74 214 <br /> t ' E H 1426 Rev. 1-74 - _ <br />