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SAN JOAQUIN LOCAL e. StoHktonCalif. <br /> FOP, OF CE USE: 1601 E. Hazelton A <br /> Telephone: (209) 466-6781 permit No. l� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued ��6 <br /> (Complete In Triplicate) ermit to construct <br /> Application is hereby made tolthe San Joaquin Local cation isealth Ditmade inrco compliance with San Joaquin <br /> and/or install the work herein described. This app Local <br /> � _ �� l/ <br /> County Ordinance Na. 1862 andithe Rules and of the San Joaquin Locaa l Health District- <br /> the Re <br /> 3Sol E.. e., � 0 Www �' f/� I 'a-L- <br /> i CENSUS TRACT <br /> k JO ADDRESS/LOCATION 6 <br /> Phone <br /> , <br /> Owner's Name <br /> city <br /> Address <br /> . S3 � <br /> License �� 'Phone jLX1 -�-"?9_? <br /> Contractor's Name <br /> DESTRUCTION /� <br /> TYPE OF WORK (Check) : 'NEW WELL / DEEPEN / I: RECONDITION I I <br /> pLTI� REPAIR / / PUMP REPLACEMENT I�T <br /> PUMP INSTALLATION I I - W <br /> Other 1 I <br /> SEWER L INES PIT PRIVY <br /> OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLnCONSTRUCTION SPECIFiCATI0N5 <br /> INTENDED USE .TYPE OF WELL ` <br /> Cable Tool Dia. of Well Excavation <br /> Industrial Drilled pia, of Well Casing <br /> Domestic/private Gauge of Casing <br /> Domestic/public Driven , <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation Rotary Type of Grout <br /> ! Cathodic Protection y Other Information <br /> DisposalOther <br /> -••-- Surface Seal Installed B : �6 <br /> l Geophysical � <br /> F �.. <br /> PUMP INSTALLATION: Contractor <br /> . Type of Pump — d <br /> C /% State <br /> PUMP REPLACEMENT: Work Done <br /> PUMP .REPAIR: / State Work' 'DoneQ - <br /> v: Approximate Depth <br /> DESTRUCTION OF WELL: Well <br /> Dia <br /> Describe Material and Procedure <br /> rict <br /> k with all laws and regulations a welleconstruction'. Within aFIFTEEN tDAYS <br /> lt <br /> I hereby agree to comply pertaining to o <br /> and the State of California p r regulating I will furnish the San Joaquin -Local Health District <br /> after completion of my work on a new well, ip <br /> F WELL DRILLERS REPORT of the est and ratify them befoeliputting. ILL �L FOR AeGROUTeabove <br /> INSPECTION <br /> information is true to the best of my knowledge <br /> PRIOR TO G_WIZING AND A FINAL INSPE ION. ITLE j* <br /> ! 51GNE <br /> I OT ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I DATE _12 <br /> APPLICATION ACCEPTED BY <br /> OY <br /> ADDITIONAI. COMMENTS: ! PHASE III/FINAL DATEE IO O <br /> PHASE II G OUT INSPECTION INSPECTION BY - <br /> t INSPECTION BY DATE <br /> =�' . 3/76 214 <br /> U 1L?A Rev. 1_74 . <br />