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I <br />FOR OFFICE USE:'If f< <br />THIS PER]Date Issued <br />Owner's Name Phone <br />Address <br />TYPE OF WORK (Check): <br />DISTANCE TO NEAREST: <br />Other <br />PUMP INSTALLATION: <br /> H.P. <br />£7 State Work Done <br />£7 State Work Done <br />DESTRUCTION OF WELL:Approximate Depth <br /> (' <br />DATE <br />6/77 .E H 1426 Rev.■1-74 2M <br />PUMP REPLACEMENT : <br />i <br />PUMP REPAIR: <br />Application is hereby <br />and/or install th <br />County Ordin, <br />r7~PIT PRIVY -- <br />CESS POOL/SEEP AGE PIT /OTHER --- <br />PUBLIC DOMESTIC WELL ---- <br />>/^ ££1 Census tract <br />---TITLE <br />>AN ON REVERSE SIDE <br />I <br />if <br />h nu t <br />JOB ADDRESS/TOCATLON <br />V<^ ( S/7 Y) I _____________ <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASfi I^fiRO <br />INSPECTION BY^V^V^X <br />Well Diameter __________ <br />Describe Material and Procedure <br />INTENDED USE <br /> Industrial <br /> Domestic/private <br />X Domestic/public <br /> Irrigation <br /> Cathodic Protection <br /> Disposal <br /> Geophysical <br />Contractor <br />Type of Pump <br />SAN JOAQUIN LOCAL HEALTH DiSTRl, <br />E. Hazelton Ave., Stockton^# <br />Telephone: (209) 4^-€r7^1 <br />APPLICATION FOR WELL CON^XRfflTflON OR PUMP PERMIT <br />SEPTIC TANK//7/y^-SEWER LIN^S /QQ <br />SEWAGE DISPOsJu^EIELD ' CESSPOC <br />'RIVATE DOMESTIC WELL TT2 <br />CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation 4 <br /> Dia. of Well Casing <br />Gauge of Casing <br /> Depth of Grout Seal <br /> Type of Grout <br />Other Information <br />Surface Seal Installed By: <br />------------- <br /> City <br />License Phone Contractor's Name <br />Permit No. <br />PLGfrp <br />FOR DEPARTMENT USE ONLY <br />_____t____________________________________ <br />OUT INSPECTION ' / W/FINAL INSPECTION <br />>_ DATE tVJVnfr INSPECTION BY V\\^V£, DATE <br />PIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />to the San Joaquin Local Health District for a permit to construct <br />ork herein described. This application is made in compliance with San Joaquin <br />e No. 1862 and^th^ .R^les and Regulations of the San Joaquin Local Health District. <br />I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />°f my W°rk °n a neW wel1’ 1 wil1 Ornish the San Joaquin Local Health District a <br />WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />P^IoTro^ °f knOW1j78e and belief. I WILL CALL FOR A GROUT INSPECTION <br />rKlUK TO GROUTING AND A FINAL INSPECTION.’7 /I ----------7------- ------------— <br />SIGNED ———————— — — v^[/i/ 1///^ j . tttt 77 £~~*" <br />---_ <br />PROPERTY LINE^PR---- <br />TYPE OF WELL <br />Cable Tool <br />Drilled <br />_ Driven <br /> Gravel Pack <br />Rotary <br />NEW WELL 22/ DEEPEN_/__/ RECONDITION_/27 DESTRUCTION /~J <br />PUMP INSTALLATION /\Z PUMP REPAIR / / PUMP REPLACEMENT - f~7 <br />Other /_/~ ~’