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SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> FOR QYFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:p (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7',-Sp g 6 <br /> THM :PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -1�- 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 land the <br /> eeRfules and Regulations of the .San Joaquin Local. Health -District. <br /> JOB ADDRESS/LOCATION G�{J �. -11`-`� 1 � CENSUS TRACT <br /> Owner's Name ✓ '� j�. Phone7�( <br /> Address ® liCl /� �-1 1% � city <br /> Contractor's NameILL- ti License # i��37,7 Phone <br /> TYPE OF WORK (Check): NEW WELL /% ` DEEPEN / -/ RECONDITION /_% DESTRUCTION /-7 <br /> . PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT g' <br /> Other <br /> �3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY rz <br /> 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 Casings'i <br /> Irrigation. Gravel Pack Depth of Grout Seal I <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor A <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: % State Work <br /> PUMP REPAIR: / / State Work Done <br /> — F <br /> 1 ,UESTRUCTION 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 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 1 <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 /> (DRAW PL PLAN ON REVERSE SIDE) E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �- ) <br /> PHASE II G IN5 ECTION PHASE I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TEer 41 <br /> CALL FOR A GROUT INSPECTION PRIOR-TO GROUTING AND FINAL INSPEC IO . i <br /> E H 1426 7/72 1M <br />