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R a j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. ZZ_ L.C2- fo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedg-�2 <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 Joaquiz <br /> County Ordinance No. 1862 and the .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 17 _ � � r Lk,r CENSUS TRACT <br /> a � <br /> Owner's Name � . <br /> C ZD" <br /> Address ~ 6' City , <br /> C <br /> Contractor's Nares ~ ' ' , _,License Phone�C - <br /> TYPE"OF-WORK.-.(Check-)-:--NEW-WELL-/ 7 " DEEPEN--7 RECONDITION 7/_7---DESTRUCTION <br /> PUMP INSTALLATION f-7 PUMP REPAIR / / PUMP�REPILACEMENT , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A PIT PRIVY 913 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation v <br /> Domestic/private Drilled A Dia4 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 /> i Other Other Information <br /> Sl- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. <br /> I � � <br /> PUMP REPLACEMENT: State Work Done ' _ <br /> PUMP REPAIR: / !J State Work Done . <br /> RESTRUCTION OF WELL: __Weli Diameter a Approximate Depth"" <br /> Describe Material and Procedure VY <br /> i { <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> k 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 /> F information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> 11 (D LOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> DEPARTMENT USE ONLY / <br /> ' ' <br /> APPLICATION ACCEPTED BY ! DATES, <br /> ADDITIONAL COMMENTS: <br /> PHASE gpKtPHASE II FINAL INSPECIZON <br /> INSPECTION BY Z ebATEvINSPECTION BY Otto DATE •- <br /> { CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. r <br /> L H 1426 7/72 1M "`- <br /> 1' <br />