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USAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. p <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERNIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Za <br /> (Complete In Triplicate) , <br /> o construct <br /> Applf cation is hereby k herein he San Joaquin described. This oapplication iscal Health tmade in ao plrict for a ianceit twith San Joaquin <br /> and/or install the work h <br /> County Ordinance No.. 1862 andithe Rules and, Rehu of the an Joaquin Local Health District. <br /> ct a4-I q JCcENSUS TRII��z^ <br /> JOB ADDRESS/LOCATION 0`' o Off" ✓ �f/ <br /> Phone# <br /> Owner's Name <br /> .. City <br /> Address �1► <br /> t. Li-ease l�/Phone <br /> Contractor's Name it <br /> E TYPE OF WORK (Check)i NEW WELL DEEPEN '/� RECONDITION / DESTRUCTION %T <br /> !; <br /> j PUMP. INSTALLATION .I I REPAIR /./ PUMP REPLACEMENT,_�� <br /> Other's/ 1 " <br /> j SEWER LINES PIT PRIVY rr t,. <br /> j DISTANCE TO NEAREST , SEi'TIC'TANK� ---•-_.�.= CESSPOOL/SL�EPAGE PIT -OTHER: <br /> r i SEWAGE,DISPOSAL FIELD PUBLIC DOMESTIC WELL- <br /> L PROPERTY LINE - PRIVATE DOMESTIC'WELL` <br /> INTENDED' USE { TYPEOF WELL CONSTRUCTION SPECIFICATIONS ; <br /> Cable Tool Di"a: of Well Excavation <br /> t Industrial ; Dia. of Well Casing <br /> :: bomestic/private Drilled <br /> + Domestic'/public _:. <br /> Driven Gauge of Casing f <br /> Irrigation �:_ -► Gravel Pack <br /> Depth of Grout .Seal <br /> Rota Type of Grout <br /> Cathodic`Protection �!'; ' Other Information �1 <br /> Disposals 10ther , _ <br /> I Surface Seal -Installed BY: <br /> Geophysical <br /> pi1MP INSTALLATION: contractor' H.P. <br /> Type oP Pump <br /> pUVpp REPLACEMENT": - %/ State =Work Done M <br /> M ILIJ) <br /> State Work Done ' <br /> PUMP .REPAIR: � <br /> IF k __ ,,..;,,,,,�.;,,....��•. �PproximateTIIepth <br /> DESTRUCTION OF WELL: ✓Well Diameter- ----- - <br /> { i Describe Material and Procedure t A <br /> rict <br /> ocal <br /> I hereby agree �.to eompl�► with all laws and r-reregululat�ngpweld~�coustructi�n—f the San oaq in LIFTEEN�3iAYS <br /> and the State of California pertaining-to o $ <br /> after completion oj(my-wort. on a new well, I will famish the San Joaquin Local Health District a <br /> WELL DRILLERS RE Ong the ,well in use. The above <br /> RT of the' well and nktio�led emandfbeliefore ttil WILL CALL FOR AGROUT-----INSPECTION <br /> information is true to the-best of my knowledge <br /> TO GROUT NG AND A FI I PE ION. TITLE s <br /> SIGNED , I`•. <br /> D W•P T'PLAN ON REVERSE SIDE . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' DAV6- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II, GROUT INSPECTION DATE <br /> INSPECTION BY 31 DATE /& " �.� INSPECTION BY <br /> 3/70 2M <br /> E H 1426 Rev. 1-74 <br />