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t <br /> SAN JOA UIN LOC <br /> FOP1rO FICE USE: ICT <br /> 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . <br /> Permit No. 7 � <br /> THIS PERMIT -7----------- <br /> EXPIRES1 YEAR FROM V DATE- ISSUED--% Date 'Issued/ <br /> Apps#cation is hereby made to the San (JoaComquin Local: ete In Triplicate <br /> Hepalth Di -- �. <br /> rY,, <br /> and/or install the work herein described. This a Ifcation istmade �n comPlfanceTmit ,twi-onstr Jt ' <br /> County Ordinance No. 1862 and the Rules and Regulations.:of the San Joaqufn Local-Heath Df r <br /> r rict. <br /> JOB ADDRESS/LOCATION ' strict. <br /> Owner's Name 5 CENSUS TRACT <br /> Address t/ �/� - r Phone } <br /> Lj - .....-... ... _... . ,_.. city <br /> Contractor's <br /> Contractor's Name <br /> f <br /> License #' _ Ph one <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /`7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /—/—PUMP PUMP REPLACEI�N�E7. i <br /> Cather /% <br /> r { <br />_ DISTANCE TO NEAREST SEPTIC TANK <br /> SEWER LINESZ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/.SEEPAGE PIT <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL/ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> dustrial Cable Tool Dia.. <br /> SPECIFYCATIONS. <br /> Domestic Dia.. of. Well Excavation <br /> /Private ��Drilled Dia: of We11 .Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing, k. ., . <br /> _ Cathodic Protection ""- Gravel Pack Depth of GrouL`Seal , <br /> Dis Rotary <br /> ,� osal ^Type-of-Grout � _ <br /> A <br /> Geophysical OtherOther_ OthInformation <br /> � .- <br /> .. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor T <br /> Type of Pu <br /> mA E <br /> t.. Hip. <br /> _ _ 1 <br /> PUMP REPLACEMENT; State Work Do � <br /> ne ; v , <br /> PUMP :REPAIR: L State Work Done T. <br /> , . <br /> -------------- <br /> ESTRi]CTION OF WELL: 1 Well. Diameter - - <br /> Describe Material-and-Procedure APA, xi mate Depth <br /> I hereby agree to comply with all laws and egulations of the San Joaquin Local Health ) <br /> and the State of California pertaining to or regulating well construction. Within -FIPTEEN DAYS <br /> District <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the .well in use. <br /> Information is true to the best of my knowledge and belief. I WILL The above <br /> PRIOR TO GROUTING D <br /> FINAL I E ION. L F{�R A GROUT INSPECTION <br /> 5IGNED � <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FORD TMENT U E ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS; <br /> DATE /"'. -7� <br /> PHASE II GROUT IN PECTION <br /> INSPECTION BY DATE PHASE III F NAL INSPECTION ' <br /> INSPECTION BY DATE <br /> E .H 1426 Rev. 1-74 <br /> �, <br />