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y.. } I- /OGS <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT f�� 0, ,app �11 <br /> 96- <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. � <br /> Telephone: (209) 466-6781 �'. 3- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> THIS: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> i <br /> (Complete In Triplicate) <br /> Application is hereby made to''the San a�uThisoapplication iscal Health tmade inrict rcompliancea permit twith nSan uJoaquini <br /> and/or install the work herein described. <br /> lations of the San <br /> County Ordinance No. 1862 and the Rules and ReguJoaquin focal Health District. <br /> ( 1Zi�f6 CENSUS TRACT ' . <br /> JOB ADDRESS/LOCATION ON ` <br /> Phone <br /> Owner's Name <br /> city <br /> Address ®. � <br /> License Phn,e <br /> Contractor's Name <br /> � 1 <br /> -7 DSTRUCTION <br /> TYPE OF WORK (Check) : NEW WELL ef__%EEPEN / RECONDITION / EPCEMENPUMP -L7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / <br /> j Other, <br /> i <br /> SEWER LINES PIT PRIVY <br /> I DISTANCE TO NEAREST: SEPTICt AN 1 _ CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE .DISPOSAL FIELD,70_0 <br /> STIC WELL <br /> PROPERTY LINE - PRIVATE D(}MESTIC WELL CONSTRUCTION —SPECLIC IFICATIONS <br /> INTENDED USE TYPE OF WELL Q <br /> Cable Tool Dia. of We11 Excavation <br /> Industrial Dia. of Well Casing <br /> Domestic/private I Drilled <br /> Driven Gauge of Casing <br /> Domestic/public 1 Depth of Grout Seal <br /> ��Irrigatian j �Gravel Pack PIV If <br /> Type of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal . I Other ^_______� <br /> Surface Seal Installed BY'-:; <br /> Geophysical <br /> rector <br /> RA�OA - <br /> PUMP INSTALLATION: ContH.P. E1 <br /> Type of Pump �P <br /> PUMPREPLACEMENT: <br /> ' State Work Done <br /> PUMPREPAIR: / / fD <br /> tateWork Done <br /> DES-TRUCTION OF WELL: WelliameterApproximate DepthDescbe Material and Procedure <br /> cal. Hi <br /> I hereby' agree to comply with all laws and regulations of ll'co struction.Lo <br /> ereWithin aFIFTEENtrict DAYS <br /> 3 <br /> and the State of California pertaining to or regulating we <br /> after completion of my work on a new well, I .ill <br /> beforesputtingthe San <br /> Joaquin <br /> welliLocal <br /> useHTheealth DDisterict a <br /> WELL DRILLERS REPORT of thetwell and notify them <br /> ' lo owledge and belief. I WILL CALL FOR A GROUT INSPECTI94, <br /> information is true to the best of- my <br /> PRIOR 11 <br /> TO RO TING AN A FINAL INSPECT TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> FOR VARTMENT USE ONLY <br /> PHASE I , DATE <br /> %PLICATION ACCEPTED BY <br /> IhIT10TAL COMMENTS. : p ITI/ ANAL N$PECTIO <br /> q, PHASE I GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE " <br /> . 1 1/77 . 2M <br /> x ` <br /> 1)o.r_ 1-74 <br />