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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: AAP <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .20 cIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DateSls�ed G <br /> Z lP ! M ELi-4 Or-72-6 (6iplete 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 /> �,qqnty Ordinanwce No. 1862 and the Rules and Regulations- of the San Joaquin Local Health District. <br /> ? S-S/�,OCAT�ON /�, !- .j��., .��!/(� CENSUS TRACT <br /> fly <br /> Owner's Dame _ . Phone� <br /> Address r /V , .t� /. / ZLD City lJ/Jif. <br /> ' r <br /> Contractor`s Name License-4 f . ' Phone s� ' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /'7 DESTRUCTION /7 <br /> PUMP IN_A�.LATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /-7 N <br /> Other / / , <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ter_ <br /> Other Rotary Type-m-of- Grout 7-() -� f' ,f . <br /> Other Other Information T <br /> PUMP INSTALLATION: Contractor <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 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/i4, true to the be f my nowledge and belief. <br /> SIGNED TITLELA <br /> (DRAW PLOT PLM ON REVERSE SI <br /> FOR DEPAATMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TOGROUTINGAND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />