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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USF: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73�z`f6 <br /> f <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 Saiz Jaaquiri <br /> County Ordinance 'No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �� 7 .5-0 <br /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Owner's Name Phone <br /> AddressM�41TA4�..g <br /> City <br /> Contractor's Name License #I �Phon rsJ�f <br /> TYPE OF WORK (Check): NEW WELL . DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 OWN F_ <br /> PUMP INSTALLATION /_/ PUMP REPAIR /_/ PUMP REPLACEMENT /- <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> '77a <br /> INTENDED ,USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 'J <br /> Domestic/private Drilled Dia. of Well Casing l t <br /> Domestic/public .•Driven Gauge of CasingT <br /> Irrigation Gravel Pack Depth of Getout Seal y � <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ~� <br /> Type of Pump H.P. <br /> PUMP_REPLACEMENT: / / State Work Done <br /> r PUME ,.REPAIR:r _----_-//--��State--Work Done <br /> k ZESTRUCTYON 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 <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 .Abr) � ` _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ' <br /> FOR DEP T USE OXLY <br /> t PHASE I <br /> APPLICATION ACCEP Y DATE <br /> ADDITIONAL COMME <br /> P ROUT INSPECTION PIKS II F AL INSPECT <br /> INSPECTION DATE �- INSPECTIO DATE <br /> \CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172. 1M <br />