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SAN JOAQUIN LOCA, STEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Av(j ;Stockton, Calif. <br /> 4 <br /> Telephone: i' '(209) 466-6781 <br /> PLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS 'PERMIT `EXPIRES ' •XEAR.eFR0MDATE ISSUED Date Issued �L <br /> {complete In Triplicate) <br /> Application i� :hereby-made .:to the�!San,Joaquin..LocaL' HO-alth District for a permit to construct F <br /> and/or install the work herein described. This'applicatzon is made in compliance with San Joaquin <br /> County Ordinance,No:." 1862- andtthe'Rules !,and Regulations of 'the San Joaquin Local Health District. <br /> -JOB ADDRESS/LOCATION 7 �o CENSUS -TRACT r <br /> Owner l s Name Os 9 - '; .. r ., Phone <br /> Address <br /> City . <br /> Contractor's Name License '# )jd7,,9Lj Phone a I <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/X/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION I I PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> �. <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 f1 <br /> Domestic/public Driven-- iGauge of Casing � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary "Type of Grout <br /> Other other-,Information <br /> AJ Y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> _ F . <br /> PUMP REPLACEMENT: / / State Work Done <br /> w <br /> PUMP REPAIR: / / State 'Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and ProcedureG <br /> I <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <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 there before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE t� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / DATE / <br /> ADDITIONAL COMMENTS: // <br /> PHASE II GROUT INSPEC 'r3N PHASE AIIxIF INAL INSPECTI N <br /> INSPECTION BY DATE �TSPEC DATE <br /> ` CALL FOR A.GROUT INSPECTION ,PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> -E H 1426 , 4/72 1M <br />