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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf. O1PICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'3__3 050 <br /> - 07/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7- z 73 <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 Di.sprict. <br /> JOB ADDRESS/LOCATION ✓, � cf' r_ . Y ! CENSUS TRACT <br /> � 1 <br /> Owner's Name Phone <br /> Address % = � �cb City - <br /> Contractor's Name � ��- �!c 4 k 4 License #& Phone <br /> TYPE OF.WORK (Check) : NEW WELT. 'o", DEEPEN / RECONDITION J / DESTRUCTIONS /`7 T — <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER lIZ' <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 <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor ����--��� <br /> Type of Pump ems - H.P. <br /> . <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP UPAIR / / State Work Dome <br /> ,DF�TRUCTION 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. Heal-th District � <br /> and the State of California <br /> pertaining to or regulating we11''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 i ue t e- best of my knowledge and belief: r <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br />' ADDITIONAL COMMENTS: + <br /> PHASEIII GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY . DATE ._. -- INSPECTION. BY__ t. . DATE _` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL .INSPECTION. <br /> V 7A,)4 <br />