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_ L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF CE .USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> 73- 4-02 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued- <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. <br /> JOB ADDRESS LOCATION C� ?f� /" i� q�n � <br /> ADDRESS/LOCATION _ __ � iYl1"'�I CENSUS TRACT <br /> Owner's NamePhone 201 <br /> rr <br /> Address G_ - C9� ���� City <br /> Contractor's Name / //// al f License # �1�� Pho❑ -'�� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION ' PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY I <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE,PIT OTHER <br />` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial -Cable Tool Dia. of Well Excavation . .,,I— <br /> ��omestic/private Drilled Dia. of Well Casing <br /> ,I5'omestic/public Driven Gauge of 'Casing <br /> /Irrigation Gravel Pack Depth of Grout SealYj'e7 �S <br /> Other Rotary Type of Grout _ _ <br /> Other Other Informations <br /> PUMP INSTALLATION: Contractor «i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J J State Work Done <br />„P?ESTRUCTION OF WELL: Well Diameter Approximate,- Depth <br /> Describe Material and Procedure <br />�I hereby� ag'ree 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 a <br /> WELL DRILLERS REPORT of the well and "notify them before putting the well in use. The above <br /> informatio . is ue to the best of my knowledge and belief. <br /> 'SIGNED TITL lei ' c�iP <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'E FOR DEPARTMENT USE ONLY i <br /> PHASE I a <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE' -7 3 INSPECTION BY DATE - j9e„�II,� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND :FINAL.'INSPECTION.. �� n� <br /> E H -1426 7/72 1M <br />