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/U SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI USE: 1601 E. Hazelton.Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT " Permit No.-/Z- 9 e 9 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued <br /> 7 Zr <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 11 an& the :Rules and Regulations of the San Joaquin Loca17"Health District. <br /> JOB ADDRESS/LOCATION Q CENSUS TRACT " �j— <br /> qI <br /> Owner.'s� Name <br /> Phone <br /> AddressT CityC p� <br /> "Contractor's Name ®, �. y -License # Phone <br /> TYPE OF WORK (Check) : NEW WELL "/ / DEEPEN:/, ./ RECONDITION /7 DESTRUCTION /' <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER+LINES PIT PRIVY <br /> SEWAGE DISPOSAL:FIELD CESSPOOL/SEEPAGE PIT } OTHER <br /> i <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 Gravels Pack Depth.:of _Grout. Seal.-.,�. <br /> Other Rotary Type of Grout " <br /> Other -_ Other Information <br /> PUMP INSTALLATION: Contractor F <br /> Type of Pump r tel" <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUNP REPAIR: A_jr State Work Done C <br />,r. . . <br /> d ti <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> L <br /> l , <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 /> .y 3 <br /> SIGNED % - ,,,} - A .c 'LE- <br /> (DRAW <br /> LE-(DRAW PLOT PLAN ON REVERSE SIDE) k <br /> D ' TENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEP DATE - 5- <br /> ADDITIONAL COMMENTS: 7 ' <br /> } <br /> PHASE II GROUT INSPECTION P INAL INSPEC ON <br /> INSPECTION BY DATE INSPECTION BY DATE Z,_...... <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4/72 1M <br />