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a <br /> 5ANTJOADt1IN LOCAL HEALTH T?ISTRICT <br /> [EFORX.F_ICE USE: 1601.,. Haz*i1„tpn`.Ave., Stockton, Calif. <br /> Tlea e (209) 466-6781 <br /> APPL TI N" ;WELLiCONSTRUCTION OR PUMP PERMIT Permit No. 72--to3 <br /> -'' THIS PERMIT EXPIRES-1 YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In -Triplicate) <br /> Application is hereby made"-to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This-application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. k <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's MName' Phone <br /> Ad SA122 City FSC,4.0,11 <br /> License # . . Phone <br /> C"etorwame <br /> IZ ,.:- 3 <br /> TYX-MOF�,WORZ (Aheck} ; NEW WELL-/ / DEEPEN '/ / RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION /�/ PUMP REPAIR / / PUMP REPLACEMENT 14 <br /> c, Other97 n5) <br /> I I <br /> DISTANCE TO `.NESREST: - SEPTIC TANK SEWER LINES PIT PRIVY <br /> - -`r SEWAGE .DISPOSAL FIELD,.. CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ° Gravel Pack Depth of Grout Seal w <br /> Other Rotary Type of Grout ' . <br /> Other Other Information. <br /> PUMP INSTALLATION: Contractor E <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done / - ` '� ��• - d <br />'L IPUMP_REFAIR:�...-,- -/—/ State Work Done <br /> - u <br /> .DESTRUCTION OF WELL: Well Diameter ti. 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 />'4 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 a <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. <br /> SIGNED <br /> TITLE <br /> - --- <br /> (DRAW PL9T PLAN ON REVERSE SIDE) <br /> FOIY DEPARTMENT USE ONLY <br /> PHASE I DATE ' S <br /> APPLICATION ACCEPTED BY <br /> 62L— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III FIN L INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H'1426 <br /> 4/72 <br />