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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. 's L 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued -S =z" -7 <br /> �f (Complete In Triplicate) A-�•j <br /> Application is hereby made t�O the San Joaquin Local. Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <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 n .Lcr 4.� d V 1,,T_ - _ Phone ` <br /> F <br /> Address Y,j 16,-LZIo City <br /> 17 <br /> Contractor's Name License # ./ Phoned <br /> e <br /> TYPE-OF WORK„(Check) : NEW WELL / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /� <br /> PUMP INSTALLATION/ / . 'UMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Itit <br /> Industrial Cable Tool Dia. of Well, Excavation <br /> f Domestic/private Drilled Dia. of Well Casing S <br /> � 1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal fi <br /> Other Rotary Type of Grout <br /> Other- Other Information ' <br /> i PUMP' INSTALLATION: Contractot �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 /> after completion of my work on a new well, I will furnish the Sari 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 /> SIGNEDTITLE <br /> (DRAW PLOT 15LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> -APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASF,II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY� 1`-)JPr - DATE INSPECTION BY DATE A- 14- 9;L <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1 <br />