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*SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton,. Calif. <br /> Telephone: (209) 466-6781 PERMIT permit No. 7A <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> YDate Issued l/:3-7� <br /> THIS PERMIT EXPIRES l'YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) ruct <br /> Application is Hereby made -to the SanJoaquin Local ieatianth Distmade .inrcompliancetwith nSan Joaquin <br /> APP T PP <br /> and/or install the work herein describ la OI „joaq.un Local .Health District. <br /> County Ordinance Na. 1862 and the-Ru and r <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATIO <br /> Phone <br /> Owner's Na <br /> City ; <br /> Address. r <br /> License <br /> Contractor's Name <br /> DESTRUCT] <br /> ON T/�T <br /> TYPE OF WORK (Check) : NEW WELL I�I DEEPEN %/ RECONDITIO 17 <br /> PUMP ALT.ATION -/ / PUMP REPAIR PUMP REPLACEMENT 1_7INST <br /> Other I I T � . <br /> SEWER LINES _ PIT PRIVY <br /> DISTANCE TO NEAREST:- SEPTIC -TANK CESSPOOL/SEEPAGE PIT OTHER _ <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL ( <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS W <br /> INTENDED USE TYPE OF WELL <br /> Cable Tool. Dia. of Well Excavation - <br /> Industrial Drilled Dia. of Well Casing <br /> Domestic/private Gauge of Casing <br /> Domestic/public Driven Depth of Grout Seal <br /> Irrigation Grave]. Pack <br /> Rotary Type `of Grout <br /> Cathodic ProtectionOther other Information <br /> Disposal Surface Seal Installed BY: <br /> Geophysical ' <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type= of Pump t . . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: - .' State�Work Done <br /> + Approximate Depth c <br /> DES-TRUCTION OF WELL: eter <br /> Describeell mMater ial and Procedure <br /> San <br /> uin <br /> cal <br /> riCt <br /> I hereby agree to comply with all laws-and regulations of the onstruction.LoWith naFIFTEENtDAYS <br /> and the State of California pertaining to or -regulating 1,furnishethecSan Joaquin Local Health District <br /> after completion of my work on' a new well, <br /> WELL DRILLERS REPORT .o£ the well and notify them before putting the -well in use. The above <br /> rue to the best of my -knowledge and belief. I WILL CALL FOR A GROUT <br /> information is tINSPECTION <br /> PRIOR TO GROUTING�`AND, 11 A FINAL INSPECTION. TITLE . <br /> SIGNED jj T' PL070N REVERSE SIDE <br /> 4 <br /> TP4SNT USE ONLY <br /> OR E <br /> PAR <br /> D <br /> PHASE I . '' DATE — <br /> AP� PLICATION ACCEPTED 'By _ r <br /> s ADDITIONAL TION COMMENTS: PHA <br /> NSP I I/FINAL INSP ON <br /> PHASE II INSPECTION BY <br /> 114SPECTION BY DATE <br /> - - _ 3/76 2M <br /> R. R 1426 Rev. 1-74 <br />