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f <br /> SAN JOAQUIN LOCAL HEALTH DIST'RTCT <br /> FOR OFFICE USE: 1601 E. Hazelton.Ave. , -Stockton, Calif. <br /> Telephone: (209) 466-6181 ' <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Ls 7-3 <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED , Date Issued Zj- 7 A-- <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 ® L fJ Cvd l/( CENSUS TRACT <br /> I Phone ��` �✓l <br /> owner's Name ` - K <br /> Address City J lJ LfJLC. <br /> Contractor's Name License # �Q`l Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN '/_/ RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation O <br /> t ::7�_ Domestic/private Drilled Dia. of Well Casing U <br /> Domestic/public Driven Gauge of Casing — &-7- , `V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout OGS l l <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> - - Type of Pump - H.P. <br /> PUMP REPLACEMENT: / State Work D,4 e <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe Material and Procedure <br /> I hereby agree comply a to with all laws and regulations of the San Joaquin Local Health District <br /> P Y <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 /> information is true to the best of my knowledge and belief. <br /> SIGNED �� TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �� z <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: Ar 2-7 <br /> PHASE I U T - PHASE IIILFTNAL INSPECTION <br /> INSPECTION BYDATE fl� INSPECTION BY DATE - U~ <br /> CALL FOR A SR&T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �_X..I. ��- wtxx-- V�tt`d' �* — 4/72 1M <br /> G <br />