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SAN JOAQUW- ,,LOCAL HEALTH DISTRICT <br /> FOR OFFI USE: 160i E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> J <br /> 1 THIS PERMIT EXPIRES 3 YEAR FROM DATE ISSUED Date Issued -173 <br /> (Complete In Triplicate) <br /> Applicationis hereby made to the San ,Joaquin Local Health District for a permit to construct <br /> r and/or install the work herein described. This application is made in compliance with San .Joaquin <br /> County Ordinance No. 3862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION 4 �. CENSUS TRACT ' <br /> Owner's Name 1 F <br /> i Phone Y�Y G j,Fl <br /> Address <br /> City <br /> Contractor's Name 1 License # L Q Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION / / DESTRUCTION 1`7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS � <br /> Industrial �� Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> Dia, of Well Casing � <br /> Domestic/public Driven Gauge of Casing ':Irri <br /> Irrigation Gravel Pack <br /> i` <br /> Depth of Grout Seal <br /> f Other - Rotary Type of Grout <br /> Other Other Information 6T <br /> - 5 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - , H.P. <br /> F PUMP REPLACEMENT: I <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> " Describe Material. and Procedure <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-wel'lAlcanstruction. Within FIFTEEN DAYS= <br /> after completion of my work on a new well, 'I will furnish the San Joaquin Local Health District a f <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informationF'is true to the best of my knowledge and belief. <br /> SIGNED TITLE 4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -- <br /> APPLICATION-ACCEPTED BY DATE- =- <br /> ADDITIONAL COMMENTS: � <br /> PHASE II GROUP INSPECTION' PHASE III FINAL INSPECTION I <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. 4 <br /> E H 3426 Y'. <br /> 7/72 v 1M <br />