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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Z3-:L&-j V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued �1--7-73 <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 Sart Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION ��� CENSUS TRACT <br /> Owner's Name Phone 301y_ cS� <br /> Address YO City ' l/Ly <br /> Contractor's Name4 4 C /+ License # Phone � B� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ j RECONDITION / / DESTRUCTION /_7 <br /> PUMP INST CATION PUMP REPAIR / / PUMP REPLACEMENT 1-7' <br /> Other / j <br /> DISTANCE TO NEAREST: SEPTIC TA:3K . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> INTENDED USE TYP . OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable 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 <br /> Other Rotary Type of. Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractori4h►►' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: /7_7 State Work Done <br /> .DFgTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sart 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 DRILLER ORT of .the well and notify them before putting the well in use. The above 1 <br /> information i tr a to the est of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PIAN ON REVERSE SIDE) I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY //ff//J DATE /I ~3--7_3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION j <br /> INSPECTION BY 4&eDATE / - INSPECTION BY DATE// --Z 7 � i <br /> I <br />'. :.CALL FOR A GROUT. INSPECTION -PRIOR TO GROUTING AND FINAL INSPECTION. <br />