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SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOh OFF7E USE: ` <br /> f Telephone: (209) 466-6781 LJ=permit No. �o �- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT �-��. <br /> d [ <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> (Complete in Triplicate) <br /> .App rict for a permit to construct <br /> ication is Hereby made to the San Joaquin Local Health Distin ,i <br /> County instnancehNowo1862eandnthesRulesdandThis Regulati Regulais tions SaneJoaquinpLocaleHealthwith SDistrictin <br /> I <br /> 1 CENSUS TRACT �_ 1 <br /> JOB ADDRESS/LOCATION Z <br /> f Phone <br /> Owner's Name <br /> City <br /> AddressPhone: � <br /> �Coutra 's Name <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN_/ RECONDITION <br /> � _/_T DESTRUCTION /7 ' <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_T <br /> Other / / <br /> PIT <br /> { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> CESSPOOr/SEZEPA6E�T OTHER <br /> - SEWAGE-DISPOSAL"FIELD` <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL°.--� PUBLIC-DOMESTIC WELL <br /> IN ED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS Z <br /> Industrial able Tool Dia. of Well Excavation C <br /> Domestic/private Drilled Dia. of Well Casing <br /> Do stic/public Driven Gauge of Casing <br /> Gravel pack Depth of Grout Seal <br /> ' rrigation Type of Grout <br /> Cathodic Protection Rotary Other Information -- <br /> Disposal Other <br /> Surface Seal Installed By: <br /> Geophysical <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> yrUMP.REPLACEMENT:__ - / / State .Work Done. <br /> fI - <br /> PUMP 'REPAIR: / / State 'Woik-Done - <br /> � DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 3 cal Health District <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Lo <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN t <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Diatrict <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information i true to the t of my knowledge and belief. ,j WILL CA FOR A GROUT IN SPEC ION <br /> I PRIOR TO GRD NG AN A F I P CT ON. �T7 TT F <br /> SIGNED ( PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE I /y7 DATE <br /> APPLICATION ACCEPTED BYy// <br /> ADDITIONAL COMMENTS: 10 PHASE ILL/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY ATE 2,� <br /> ` INSPECTION BY DATE <br /> 1/77 2M <br /> 1_76 <br />