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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. .,7,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,6 <br /> (Complete In Triplicate) ilel- Pao _3S <br /> E 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 Joaquin Local. Health District. <br /> z l u�lmv '�m �ar�l� i�'n �NSUS TRACT <br /> JOB ADDRESS/LOCATION -- <br /> Owner's Name e 7-,ex Phone <br /> Address ZS-/S k) IsnLct r 2 City ILTa 1k�u <br /> f <br /> Con <br /> tractor`s Name <br /> �� m ' r� License # CS Phone <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN / / RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 57 <br /> Other <br /> 1 E- <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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Z:_� <br /> Type of Pump j/ 1 H.P. (Qp <br /> PUMP REPLACEMENT: /x/ State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 /> t. 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 arid'belief'. <br /> �/ <br /> SIGNED TITLE <br /> ((DOW PLOT PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �a �� Ina, <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY m I 0�_ DATE INSPECTION BY DATE 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> -E H 1426 7/72 1M <br />