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POE''OFFICE USE:' <br />THIS perm:Date Issued <br />Owner's Name Phone <br />Address <br />TYPE OF WORK (Check): <br />DISTANCE TO NEAREST: <br />Other <br />PUMP INSTALLATION: <br />€ z. < S /nzt &H.P.4- <br />PUMPREPLACEMENT:/_/State Work Done <br />/ /'PUMP REPAIR:State Work Done <br />DESTRUCTION OF WELL:Approximate Depth <br />2wzeDATE <br />6/77 .2ME H 1426 Rev.■1-74 <br />i Local Health District <br />CL{ '('Ci/fU'Ly.h hfcLkL '^CENSUS TRACT <br />Well Diameter <br />Describe Material and Procedure <br />Contractor <br />Type of Pump <br />INTENDED USE <br /> Industrial <br /> Domestic/private <br />X Domestic/public <br /> Irrigation <br /> Cathodic Protection <br />Disposal <br />Geophysical <br />,GROUT INSPECTION <br />i DATE * <br />Permit No. <br />--- ---- CESSPOOL/SEEPAGE PIT /^/ -/—OTHER ' <br />RIVATE DOMESTIC WELL <br />TYPE OF WELL <br />Cable Tool <br />% Drilled <br /> Driven <br /> Gravel Pack <br />X Rotary <br />72 4 <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: <br />PHASfi I^GRC <br />INSPECTION <br /> City <br />License Phone <br />SEPTIC TANK SEWER LINES /QQ /-^IT PRIVY <br />SEWAGE DISPOS^LJFIELD _ CESSPOOL/SEEPAGE PIT /-/—OTHER ' <br />PROPERTY LINE^-^PRIVATE DOMESTIC WELL TZS PUBLIC DOMESTIC WELL ~~ZZ1 <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation <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 />PIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />to the San Joaquin Local Health District for a permit to construct <br />t^ork herein described. This application is made in compliance with San Joaqu <br />. 1862 and^th^Rj^les and Regulations of the San Joaquin <br />JOB ADDRESS/tOCAPfrGN Zt/S <br />Contractor's Name eLWii/un^ <br />NEW WELL y7 DEEPEN_/_/ RECONDITION-l_l DESTRUCTION /V <br />PUMP INSTALLATION /X/ PUMP REPAIR / / PUMP REPLACEMENT <br />Other / / <br />S JOAQUIN LOCAL HEALTH DISTRICT <br />1601 .. Hazelton Ave., Stockton>^4?aT <br />Telephone: (209) 46^-67^1 <br />APPLICATION FOR WELL CONSJfWCflON OR PUMP PERMIT <br />Application is hereby <br />and/or install thg^ <br />County Ordin^KtfeNo <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 />after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br />WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />PRIOR TO GROUTING AND A FINAL INSPECTION '— <br />ilGNED r-jM/fan.1 --mtie ///< <br />(DRAtTPLaTr PZAN ON REVERSE SIDE) / <br />FOR DEPARTMENT USE ONLY <br />INSPECTION / PHAS& W/FINAL INSPECTION <br />INSPECTION BY DATE