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�Y C 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.751- 4,,) <br /> 7.3-X97 <br /> THIS PERMIT EXPIRES l 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 San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaqui Local Health District. <br /> JOB ADDRESS/'teeffl-9A D r-f ,f �` NSUSyTRACT <br /> Owner's Name �. .�°� ��' .G$. A_ <br /> I <br /> Phone <br /> Address <br /> City <br /> Contractor's Name License ���hone s on <br /> TYPE OF WORK-(Check): NEW WELL / -DEEPEN"/-7 RECONDITION /_7 DESTRUCff0_ff"/_7 '_ <br /> PUMP INSTALLATION PUNP REPAIR /% PUMP REPLACEMENT / <br /> Other <br /> � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY ' <br /> ! SEWAGE DISPOSAL FIELD 0 "L/SEEPAGE PIT /®d -OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private — e Drilled Dia, of Well Casing 143 <br /> _ Domestic/public Driven Gauge of Casing 13 <br /> IF ko� Irrigation Gravel Pack Depth of Grout Seal, <br /> Other Rotary Type of Grout6 <br /> , <br /> Other Other Information <br /> PUMP INSTALLATION; •: Contractor - �i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION 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 o€ 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 j <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 ,fes <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY E- - DATE � � <br /> ADDITIONAL COMMENTS: <br /> PRASE .LL GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE r7,3 INSPECTION BY DATF <br /> I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. `` E <br /> E H 1426 7/72 1M <br />