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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel ton:Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION- OR PUMP PERMIT Permit No. Z6-GoD � <br /> S <br /> THIS PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED Date Issued =ate-71 <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 Joaquir <br /> County Ordinance No. 1862• and the; Rules and,-Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's 'Name - /• Phone- ° <br /> Address _ City <br /> N Contractor's Name22& ".. �L License 4L,jgyfyPhone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTAL ATION '/ / PUMP REPAIR '/ / PUMP REPLACEMENT -m- <br /> ,. Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Z SEWER LINES PIT PRIVY <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 WEII Casing <br /> Domestic/public Driven Gauge of Casing ZQ_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other . j,-" Rotary Type of Grout <br /> Other Other Informatioi <br /> } PUMP INSTALLATION: Contractor \ <br /> Type of Pum H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done ` <br /> PUMP REPAIR: / / State Work Done <br /> A <br /> 3 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 of California pertaining to or regulating well. construction. Within FIF'T'EEN DAYS <br /> ! after completion of my' work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is trueAtothe best o .. my knowledge and belief. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> VV FOR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY _,,_ 'Z' te __- _ DATE 4 - -S`"7d <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE T <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E <br /> 11 1426 � 4/72 1M <br />